MFCM028: A Note on Teaching of Community Medicine: A Critique and a few Suggestions.pdf

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A NOTE ON TEACHING OF COMMUNITY MEDICINE s
A CRITIQUE AND A FEW SUGGESTIONS

One of the criticisms MFC faces is that it is always criticising
and there have not been enough constructive suggestions. Hopefully
10th annual meet of MFC at Calcutta will help correct this impression.
A Clarification on Use of Terms*

At the very beginning we would like to clarify that the terms
’Community Health* and ’community medicine* have been rather loosely
used in the sense that they are both interch ...ngeble. They both may
have different shades of meaning in different contexts, but for our
argument, we would like to skirt the whole debate on precise defini­
tion of the terms ’community health’ Vs ’community medicine1 simply
because they serve no purpose other than diverting the attention from
much more crucial and difficult problems.
What is Community Healthy? L & Problem and Its Scope.

A friend, final year medical student, fine fellow, sensitive,
intelligent, concerned; and eager to know about the wrongs in existing
health system once asked ” but what is community health ? how does
one ’practice* it ? I can understand and make clinical diagnosis but
how can I make ’community diagnosis’ or how can I ’do’ community treatment ? *’
This note keeps these and similar questions and similar medicos
in mind whose concern for social ills is beyond question, who are not
self-seekers or purely carrier-oriented. They are not blind to pro­
blems of neglected, exploited unorganised poor people. These simple
looking questions are, in fact, loaded questions. These questions
have to do with teaching of community medicine in the medical colleges
in our country today. Before we go further we must stress one point
that it is not and can not be a thorough-going, fully-developed
argument. The teaching of community health is too vast and complicated
a problem to be dealt with full justice by a small group like us with
a limited experience in community health.
Hold of Traditional Medical Education on Its Critics 1

We start with the very choice in this meet of teaching of commu­
nity medicine as one of the subjects in medical education. This is a
mistake in our opinion and reflects the strong-hold, the orthodox and
traditional mode of teaching health sciences still has on our minds
despite our valiant efforts to throw away the hidden assumptions and
theories of teaching health sciences in traditional ways.
Another aspect of the same phenomenon of hold of traditional mode
of medical education on our minds is to be seen in the fairly wide­
spread belief even amongst the critics of medical education that a
number of progressive changes have been made in the series of recomm­
endations made by various high level committees on medical education
since independence. The critics feel that atleast part of the
problem can bo solved by implementing the progressive changes honestly
and sincerely. We believe that far from being progressive, they are
merely cosmetic changes. They provide for no progress in medical education.
In the traditional teaching, science of health has been broken
down into a series of rigid pigeon-holes (e.g. anatomy, physiology,
pathology, medicine, surgery, OB and GY, community medicine...etc.)
precluding almost any interaction among them. The organib unity of
all disciplines in the context of their theoretical relationships as
well as in the context of their application in practice is disrupted
mindlessly for all practical purposes.
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A sort of divisions of disciplines is necessary on practical
grounds only, but when community medicine is included as one among
many subjects to be learnt,the situation begins to approach absurdity.
A couple of years ago, a well-known community health worker in India
made a very significant observation that creation of Departments of
Preventive and Social Medicine and subsequent. separation of a subject
of PSM in the medical colleges (a progressive change) had dealt a sev­
ere blow to the development of the concept of teaching and practice of
community medicine.. Now since the Departments of PSM were there, it
was their sole responsibility to teach community medicine; other depa­
rtments could carry on as they liked J The ^armful harvests of such
thoughtless and shortsighted decisions are being reaped now. •

The notion of a community medicine as a separate subject has its
roots in the way the problem of dealing with ill health has been posed.
This particular way of posing problem generates other assumptions, the­
ories and action programmes which ultimately mould ideas of - both suppo­
rters and critics of existing medical education 1 Of course, the
interests of various power centres in the society do influence and
mould particular form of medical education; but clearly this is not
an adequate explanation, because it still leaves open the interesting
problem of explaining criticism of a segment of critics whose align­
ment with power structure is unthinkable, voiced within the same frame­
work which is problematic essentially because it poses problem in one
way and not in another way. The critics must challenge the way the
problem is posed.

Prpblem Posing (of Ill Health) - The Traditional Way*
Traditional medical education largely seeks to equip students to
deal with an individual patient who comes to doctor for help. Virtually
whole medical education starting from anatomy, physiology through path­
ology and pharmacology to individual clinical subjects is geared towar­
ds an individual who perceives illness and seeks help from a doctor at
a predecided place called dispensary or hospital.
(here again mostly
hospital.)

Ofcourse, what can be called basic scie ces like physiology, bact­
eriology, pathology, biochemistry, parasitology,
immunology, pharmaco­
logy ... etc in their usual settings outside the world of medical colleges do not operate on such a narrow base and in such a disjointed
manner as they do in medical colleges. Their stupendous growth has been
possible in the first place because they have successfully blended
study on populations with study on individuals. One without another is,
ofcourse, impossible. The pundits of medical education seem to have
achieved impossible to wit, sever individual from his social,physical
biological settings 11 Alas 1 The interpenetrating reality is no
respecter of such arbitrary human divisions 1 In this framework illhealth is seen in a person in the hospital ward. His^/and his blood,
heart, liver, lungs, intestines, brain, stool and urine only is /body
brought under incredibly deep scrutiny. This narrow focus-unfortunately the only focus-on an individual and his bodily functions keeps out
this person as a member of his family, of much larger social groups to
which he belongs through kinship, residence, occupation, religion,
beliefs...etc. and his conditions of life, his work, his economic and
social placement and culture, his physical and biological environment.
The- whole education is a gigantic exercise in bedside pathology and
therapeutic methods. The disease in a person who presents himself to
a doctor in hospital is more often than not a tail end of the whole of
disease process in an individual. Natural history of the diseases..in
individuals has no place. Some of the most common diseases and less

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lethal diseases like scabies, malaria, mild anemias, moderate malnu­
trition and beginning of diseases arc hardly ever taught since they
are considered ’poor teaching material.’ Health and sickness in the
population with their possible correlations with significant social
and occupational influences are outside its province.
Problem Posing (of Ill Health)-A Community Health Way

Community health far from being a ’subject* is a point of view,
a definite way of looking at the problem of dealing .with ill health
in individuals in their social, biological and physical setting.
Community health has at its focus both individual and his environ­
ment. Community health is after all about the health of all indivi­
duals in the community and not in an artificial and unrealistic
setting celled hospital. This way of looking at a problem of illhealth
in individuals in the society cuts across the largely confused and,
therefore, sterile debate on dichotomy like curative Vs preventive
medicine. As a logical corollary to this shift of focus a similar
shift also occurs in remedial measures to be instituted.
The probl cm ch ang e s

cop s equenc es f o l lpw.

Having thus made a point that community medicine is not to be
treated as a separate 1 sub j ect*—a grave mistake made in the traditional
medical education because of narrow (and unreal) way of looking at
problem of ill health in individuals - to bo taught but should form
an overall framework within which the problem of illhealth in indivi­
duals is to be posed and examined, wo should now like to derive a
broad principle from its the principles and methods appropriate to
understanding the disease not only as an end point of pathological
processes in an individual who seeks, on his otfn, medical help but
also, indeed mainly, as a disease process which gains an entry in the
community, spreads its tentacles, consolidates and entrenches itself
in different individuals in different forms and intensities, in diff­
erent social groups, in different environments (used in a wider sense
as used above), in the community must permeate through all subjects basic sciences and socalled clinical subjects. At this stage we would
like to touch yet another controversy in the current debate on medical
education s whether the basic sciences should be taught at all ?
If yes, what? how much; and at what stage ? In our opinion it would
be nothing less than monumental blunder to do away with the teaching
of basic sciences. We also express our deep reservations about the
tendencies to suggest deep and extensive cuts in the basic sciences
on very superficial grounds of their supposedly limited utility in
actual practice. The community health must remain rigourously sci­
entific. The deep insight they have developed in the life processes
are vital for the development and growth of community health. Although
•we are proposing that basic sciences must bo taught within the frame­
work of community health, we hasten to add that we do not know enough
to suggest precise manner in which this can be achieved. Ours is an
attempt to establish a proximate principle; the detail working-out
will call for much larger efforts by people of various skills, experiences and background.
Another major consequence that follows from our main thesis that
ill health of man in society and not ill health of man in the hospital
ward should bo in the focus of medical education, the next logical
question we want to raise is s what are the health problems medical
education should be focussing on ?
This point is of crucial importance if the foregoing argument
is to retain its validity and sharpness. Indeed, without the unambigious answers to these questions, the thesis we have proposed can be
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twisted to serve more or less current model of medical education.
Disingenuous interpretations may be attached to it to mean s who­
soever comes in the hospital, his/her social setting will be taken
into account, succeeding thereby in retaining more or less intact
the present model of medical education. Paler versions of such
1 society-oriented* teaching programmes (progressive ?) are to be
seen in today’s family visits or integrated clinics (a teaching
session in the wards jointly conducted by a staff member each from
clinical medicine and PSM). A Selection of a case in this exercise
is a function in the first place of selection of patients for admi­
ssion which has little relation to health problems prevalent in the
society.

To avoid such deceptions, we should say a little more precisely,
it is not ’man in society’ in the hospital who moves under the focus
of medical education rather the focus of medical education now moves
out of the hospital to be trained on * man in society. '
Selection for medical education of health problems in society
should naturally depend on society* s experience of most common and
significant disorders which cause most mortalities, suffering and
disabilities. Selection of such problems is not always easy—even
if we ignore the pulls and pushes exerted by powerful interests in
the society. Some give and take is always inevitable.
Even so what
goes on in today* s medical education is so out of place, so otherwordly (we mean the worlds of rich and powerful in the cities of
India, USA & UK), so unrelated to India’s major health problems
that it can not be criticised enough. The actual regulative
principle which guides the design of curriculum is completely at
varience with this regulative principle to which most of those who
are somebody in medical education pay a lip service only.

Let us try to take a stock of health situation in India and see
how medical education measures up to.
Mortality is heavily concentrated in young age groups. 45 to 50%
of total mortality occurs in children below 5 years of age who consti­
tute 15 to 18% of total population. Of thes deaths more than 90%
deaths are preventable, should be prevented eventually.
In any deve­
loped country children below 5 years contribute less than 1% of the
total deaths. Comparative high proportion of death rate is found to
be concentrated in elderly population (more than 65 years). What is
more, very little can be done to prevent these deaths, or to prolong
life very substantially.

Deaths associated with pregnancy in our country is atleast 20 to
30 times more than in well-developed countries. Again as large as
95 % of these deaths can be prevented by intelligent human inter­
vention.
Why these preventable deaths occur ?
■ The most important causes of infant deaths (deaths below 1 year)
are s (1) complex interplay of Protein-Energy-Malnutrition (PBM) and
most common infections like diarrhoea, respiratory infections, and
skin infections, and (2) babies bom with low birth weight ( less
than 2.5 kg.) which is substantially a function of maternal malnu—
trition ( P.E.M.)

Deaths in children (1 to 5 year) which is 50 to 60 times more
common than in well-developed country is almost exclusively a function
of common infections and PM.

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High maternal mortality is again a function of iron deficiency
anemia which is almost hundred percent; PBM; infections after
delivery and inadequate monitoring and care during pregnancy and
labour.
Hundreds of thousands of children lose their vision due to Vit.A
deficiency. Communicable diseases like gastroenteritis, pneumonias,
scabies, malaria, T.B., leprosy, measles, and many others continue
to play havoc with community without meeting any significant resist­
ance or fight. The list of the problems can be made much longer than
this, but suffice it is to say that most mortalities and morbidities
are due to either deficiency diseases or infectious diseases or both.
Many fair-minded people might think that we are stretching our argu­
ment too far. They might argue that many progressive changes have
been introduced - more rural orientation, more about common diseases
etc. We would like to assure them again that it is not $o.

Several years after smallpox was eradicated from India. One
wonders how many medical students or for that matter members of tea­
ching staff except perhaps members from PSM Dept, know the most out­
standing elements of strategy and rationale of it which achieved such
amazing results. A pretty dangerius disease was conquered (without
any active involvement of medical colleges) and we have taken no note
of it. The history of malaria eradication is even more instructive.
The ambitious grand strategy was based on one of the finest epidemio­
logical models man has developed of infectious diseases. Superb orga­
nisational efforts went into it. Fine statistical and epidemiological
tools were developed to implement the strategy. It reached a dizzy
height of success and then came tumbling down. Why it achieved what
it did ? and why did it fail ? While this great drama was being
played out in the five lacs and seventy five thousand villages, batches
after batches of medical students were going through the motion of
medical education without much ado about malaria epidemiology and the
strategy. And this is not merely a question of teaching malaria.
A full 10 years after the elegant model of malaria epidemiology was
perfected and grand strategy to eradicate it, was pieced together;
the expert committees one after another were recommending ’progressive
changes’ in medical education to make it more responsive to social needs
taking not so much a note of malaria epidemiology and eradication
strategy. As we shall see presently the teaching of sound epidemiology
is so fundamental to teaching of community health; malaria epidemiology
and use of epidemiological and statistical tools in the eradication
strategy could have provided a strong base and an impetus to the robust
teaching of community health-to medical students, but it seems nothing
was further from the minds of these experts than this relationship.
The result was loss of great opportunity on the one hand and adding
trivial notions in medical education, on the other hand. Those who
are still convinced about ’the progressive changes’ should ask one
question to themselves s what weight is given to these changes in the
examinations both written and oral ?

Medical education in U.S. puts Ischemic Disease of Heart.(IHD) on
priority list, so does (almost) our medical education. IHD is 2nd most
prevalent disease in U.S., first being hypertension. IHD is number one
killer in the U.S. In the U.S. infant mortality is 7 times.less than.
in India. There are not any reliable studies in India to give us reli—
-able prevalence rate of IHD; but it is almost certain that prevalence
is bound to be much lower than two percents found in U.S. because of
the simple reason that a proportion of adult population at risk in India
is so much lower than in the U.S. Also most of the adult population
which lives in the rural areas is too poor, and too hard working to.
carry the load of risk factors which the U.S. adult population carries•
Contribution that IHD could be making to total mortality in India.is
bound to be infinitesimal. In any well—developed country, where infant
mortality is approaching 10/1000, in a population of the size of
Gujarat there would be less than 10 deaths in infants because of
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diarrhoea every year; where as in Gujarat where infant mortality is
much more than* 100/1000 the total number of deaths in infants every
year because of diarrhoea is expected to be 60,000 !! (based on B.
Nicholas and H. Soriano in The American Journal of Clinical Nutri­
tion 30 s September 1977). Another false notion which has gone round
in recent years and this time mainly from the critics of health system
that most prevalent diseases in India are simple. If there was a
case of more simplification than is possible or necessary this is the
one. This injurious belief we suspect is even shared by medical esta­
blishment. The dangers of such beliefs are clear. They may well lead
to a kind of smugness and complacency in whi h it is not considered
necessary to understand thoroughly the dynamics of diseases most pre­
valent in the society. This undertaking can be as trying as - if not
more - the one that has to be undertaken to understand the diseases
which dominate western medical education as well as ours. This argu­
ment is not to be interpreted to mean that the study of degenerative
and neoplastic diseases is to be completely removed from the medical
curriculum; it is to argue only that sense of proportion is needed.
In this connection let us stress again that basic sciences are as
basic to understanding our diseases as they are in degenerative and
neoplastic diseases. Protagonists of their drastic curtailment must
pause and ponder. The ignorance of medical students and teaching
staff of medical colleges about the dynamics of infectious diseases
and deficiency diseases which cause most of the mortality and morbi­
dity is to be seen to be believed.

It is impossible to defend the current focus of medical education
in India rationally. One may, ofcourse, invoke the argument of bala-ce of power in the society but it is not a rationale as the word is
normally understood.
Instead of meeting this massive challenge of infections and nutri­
tional disorders which kill and maim children and women of poor famil-ies in rural and urban areas and sap the energy of working men and
women all over the land and lead to their premature deaths, what wo
have done is to insert one subject called community medicine to be
learnt by and large from one text book of preventive and social
medicine (Textbook of preventive and Social Medicine by JOEO Park)
in the medical curriculum. This, to say the least, is mockery of
the concept of community medicine.

The Methods and Tools of Community Health.
What we have said so far in this note is to state the objectives,
the rationale thereof and overall framework in which the problem of
ill health in society should be viewed. We have also briefly alluded
to values that normally should go with this.

The real question now iss how to transfer these objectives and
values into tangible reality ?
The methods and tools by which the objectives as described above
are to be realised, assume the importance and receive attention they
deserve; only when they are viewed in such conceptual framework of
values and problems. In absence of such overall framework, as is
the case now, the vitally important methods and tools are tucked away
in neat and well-circumscribed chapters of textbook of preventive
and social medicine. These methods and tools .are then converted into
one of the countless topics to be studied during the whole course of
medical education.
(endless debates go on amongst exports as to at
which stage of medical education these 1 topics 1 are to bo taught 1

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-7Instead of forming the skeleton and sinews of methods and logic
upon which is built the knowledge of commonest disorders of body and
mind in a society, they are turned into trivial, peripheral, dull,
mechanical, bothersome, puny little things to be borne with fortitude
until the time of examination. Once this ritual is over they are
permanently forgotten and discarded without any sense of loss.
How many times we have geon total incomprehension writ large on
the faces of otherwise intelligent, well-established doctors at the
mention of words like ’epidemiology1, 1 demography1, 1 statistics’... etc.
After a prolong silence and rummaging their memories all they can
recall are words, they have heard in distant past and unarticulable,
unpleasant associations with them 1
Yes 1 they are the tools and methods of learning and doing commu­
nity health plus the core theories and elements of social sciences.
There are yet others but we will not discuss them here.

Epidemiology is neither a bundle of definitions nor a kit of
tools nor is it merely a lifeless schema of triangle of agent, host
and environment as it is naively made out to be. It is the method
and logic of health sciences rather than a science itself. It is in
the framework of epidemiology that one can understand, study and
analyse happenings like various health disorders in man in society.
It is with the help of epidemiological concepts and tools of analysis
like, prevalence; incidence, incubation period, period of infectivity;
carrier rates; risk ratios; cohort analysis; longitudinal and cross
sectional studies; case-control studies and methods and tools borrowed heavily from demography, we can understand as to why a particular
disease gets established in certain age, sex, social groups at a
certain place, at a certain time; what keeps it going ? when it
changes these characterstics, why it does so ? ; and how it relates
to other diseases in the society ? The understanding of distribution
and determinants (causes) of most important disease complex of a given
society provides us clues, pointers and methods to intervene so that
their hold on the society may lessen progressively until the time
when they are eliminated completely or tamed considerably.
Similarly Statistics is not to be looked upon as highly abstruse
mathematical formulas which are largely irrelevant for our purpose
and loaded with jargon. It should bo viewed as an invaluable aid to
introduce necessary rigor in collection, arrangement, and analysis of
observations in human or any living/non-living populations and deri-ving accurate inferences from them.

It is said about statistics in negative sense that it can be used
to prove anything, therefore not to be relieduupon. There is some'
truth in this charge but fault is not of statistics as a method or a
mean but of faulty way it is used, The best and rational way to fight
abuse of such a fine tool as statistics is to understand it ourselves,
Ever-growing literature of health sciences
know its limits and worth,
is full of contending theories, ideas and interpretations. A doctor
must be able to make reasonable assessment of these competing ideas
herself. This is possible only when they have sound grasp of basic
epidemiology and statistics. When this is not so, most of the doctors
are reduced to either fall prey to any claim that appears in.
1 pestigious 1 journals or to stick to his outdated textbooks or to
adhere dogmatically to his own clinical experiences which is very often
a ragbag of impressions only or to accept meekly what drug industries
tell them through the flood of literature which many times is dubious,
deceptive, and dishonest.
Demography as alluded above provides many tools and methods to
epidemiology. In the present medical education they have degenerated
into another bundle of informations to be learnt by rote without under­
standing or insight in these concepts, (e.g. life expectation at birth

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or at one year of ago, crude death rates, birth rates, standardisation
—direct and indirect, sex-ratio, fertility rates, infant mortality,
childhood mortality, life tables...etc., etc.) These are not merely
numbers to be memorised because a pedantic or eccentric professor
chooses to ask such silly questions in the examination. These statisticks, in fact, represent in a distilled form information about cha­
nges in the size and structure of population and the forces which
mould them. They help shed light on immensely complex and subtle
processes of health and disease in the society. For instance, high
rate of infant mortality in one society as ogainst the low rate in
another society says so much about the possible differences in two
societies which otherwise would not come to our notice and we could
not have guessed the role they play in shaping the events. Life
expectation at birth is not merely two digit number, which changes
mysteriously every decade.
It is a composite figure arrived at by
taking into account mortalities at different ages in a population.
It should prompt us to ask further questions of pattern of mortality
at different ages and the reasons thereof. The term 5 year survival
rate we have come to be familiar with in cancer treatment and progn­
osis is based on the methods of demography. Needless to say its
utility is not confined to cancer only.
Thorough analysis of the processes that determine the values of
these statistics has attained high degree of refinement amongst
health professionals in the West whereas we still do not have a
reliable system of collecting information continually from the whole
population on such vital events as births and deaths, let alone an
adequate analysis of these events to tell us what is going on in
It is symptomatic of deep malaise that has set in
the community.
our medical education with its totally upside down priority of
problems and methods, that major and crucial debate on causes,
extent and effects of such vital events as infant mortality, mal­
nutrition in children, reversed sex-ratios is being conducted in
non-health journals like Economic and Political Weekly. Need it
be said that barring a few notable exceptions the participants in
this marathon debate are non-health professionals ? Medical profe­
ssion has by and large no competence and no will to discuss such
issues which are at the heart of the health of the society.

With this we come to yet another tool c : community health s
the theories and methods of social sciences, They are indispensable
to grasp social processes as they affect the health of the community.
In the foregoing discussion we have stressed the heavy inter­
dependence of the methods and the tools of community health. This is
true of social sciences also. If epidemiology is the study of distri­
bution and determinants of health and disease in population, part of
its province is the study of social factors. Indeed every epidemio­
logical variable in some sense is a sociological variable. The
factors affecting the distribution of disease in population may be
biological and/or environmental and both have social implications.

Attributes such as sex, age...etc. have traditionally—in the
etiology section of most of the textbooks-of clinical subjects—
been treated as biological attributes only; but they obviously.
have social moaning. Concentration of diseases and deaths in certain
sex and age groups may also mean that they suffer from certain dis­
advantages because of status in the family and society and norms
associated with them. (e.g. greater female infant mortality, greater
prevalence of severe forms of PEM in female children, reversal of
sex-ratio, extremely high prevalence of iron deficiency anpmia in
young women, and higher rate of PEM in women are not function of
biology but a result of the status of women and children in family
and soci ety.).

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Disproporticnate concentration of deaths, diseases, and dis­
abilities in' rural poor-landless labourers, marginal and small
farmers, unorganised labourers in urban areas, tribals, harijans,
their women and children can not be understood by such dull and
monotonous intonations which occur regularly with little change in
the different chapters of text book of preventive and social medicine
like ’poverty, ignorance, superstition, lack of personal hygiene,
overcrowding, poor housing, poor sanitation. ... etc. 1 ’
These amorphous concepts don’t tell us what sort of economic
and social processes are at work which produce huge differences.in
economic and social opportunities to different social groups, situ­
ated at different places which all have a close bearing on the health
statuses of the groups concerned. Further more these factors are in
urgent need of more refinement and differentiation in relation to
each disease. They call for much harder work and analytical skills
than today’s medical schools are ready for.
The Result 111

When a conceptual framework like the one discussed above is
missing and perception of need to incorporate the tools and the
methods of community medicine in a manner such as discussed above
is very dim? what, happens can be seen even if hazily by a few examples given below.
1.
It was a health camp of medical students. They were asked* to
carry out nutritional survey (anthropometric) of under 5 children.
They came back bitterly complaining, 1 it was no use. No mother can
remember the birth dates of her children. What sort of mothers
they are ? If they can’t remember the dates even, what can we teach
them to care for their children better ?’ This is not an isolated
experience.
It is a part of a pattern. City-bred medical students
can not imagine let alone understand that poor mothers in the vill-ages do not organise their lives by Gregorian calendar (loosely
spoken as English calendar.) They are not in the habit of being
asked such ’pointless’ and isolated questions.
If you have time,
patience and understanding of their time framework then you get
birthdates of their children which are accurate enough for the pur­
pose of either monitoring growth or assessing their nutritional
states. They recall vividly the days and weeks when their children
were born in relation to various points of season’s cycles, agricul­
tural cycles, of various crops, Hindu or Muslim calendars or festi­
vals, provided we know about these cycles and calendars ourselves.
Not many of us know this ofcourse. This is a very small example,
but it illustrates rather well that medical education has no use of
social knowledge and experiences.

2.
A mother comes to hospital out patient with a moribund child
in her hands. Child is severely dehydrated because of diarrhoea.
Almost immediately a chorus of indignant voices arise from doctors,
nurses and medical students,
' how ignorant is she. ..how callous of
her to’ have brought child at such a late stage. ..when these people
will learn to be more responsible and caring.....‘
She will not
and cannot say that she has to go to fields every morning until
evening to earn wages which are always much less than stipulated
by minimum wages act which nobody wants to see implemented seriously.
She leaves the small ones in care of elder ones.
If she does not go
to work they go without food. Behind this dumb mother and moribund
child lies the hideous social reality which nobody wants to know or
cares about.

ORT or I.V. drip ? This is not a purely technical question.
It is certainly an instance of imbalance of salt and water, of acid
and base in child’s body fluids but we should remember that similar
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-10imbalances occur throughout the year in millions of human bodies who
are scattered in hundreds of thousands of villages who have no access
to health services. When thousands die because of such imbalances
they (these imbalances) no more can remain confined to biochemistry,
and medical education must impart this perspective to the students.
(How many.medical colleges today teach ORT with intensity and inte­
rest it deserves ?).
3.
Sometimes ago we were invited to a meeting where the question
of high infant mortality in Gujarat was to be discussed.
(Gujarat
has 3rd highest infant mortality in India.) Question was put to a
panel of paediatricians, Pat came answer; without a moment’s pause?
’because people are ignorant and superstitious. For instance in
measles people believe that it is due to visitations of a goddess
and child cannot be taken to a doctor for treatment, they therefore,
don't seek early medical help.’

Again this is not an isolated instance. We have heard this
same theme in many variations many times.
Either those who make
such statements are careless or they betray serious gaps in their
knowledge of the type we have been discussing.
a)

b)

s It is true that a child suffering from measles
is not taken to a doctor once rash begins to appear
on the body; but then at this stage of disease
doctor cannot do anything to alter the course of
disease either, even if the child is brought to him.
Most of the deaths occur because of bacterial pneumonias which occur after rashes have begun
to disappear; the time when parents are quite ready
to take the child to health service provided it is
readily available and reasonably cheap, The question
is: when epidemic of measles sweeps through the remote
villages are there adequate health service networks
to cater to their needs ?

Larger and more loaded questions like why measles which is supposed
to be a minor ailment without any consequence in well-nourished chil­
dren extorts heavy price of mortality (15 to 20 %), extensive and
serious morbidities such as loss of vision in thousands of children
and precipitation of severe nutritional crisis in high percentage
of poor parent’s children ?
A camp was organised to understand ecology of PEN and infant
mortality. Two bright medicos asked s is measles really a problem ?
Isn’t it supposed to be a mild disease after all ? We were not
surprised to hear these questions. Look for the reason — if you
are surprised-in the textbook of preventive and social medicine
(Referred above) on pages 356-58 (4th edition) where measles is
discussed. How casually and cursorily it has been discussed i One.
almost gets an impression reading his account of measles that he is
writing for and about upper socio-economic stratum of the society.
His chapters on history of community health, epidemiology, concepts
of community health in which on page 48 occurs a paragraph of about
200 words on community diagnosis which is not so bad as far as
contents go; but which is clearly meant to be memorised by medical
students and not to bo taken more seriously, sociology and health,
nutrition and health, and so on not withstanding; a great violence
is done to the cause, concept and theory of community health.
This book is supposed to be main source of ’knowledge1 of community
medicine for the medical students in India 1

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CONCLUSION •In this concluding part wo would like to discuss two points 2-

A) THE role of voluntaryh^™_jgrqui^s
It is true that voluntary health groups like MFC have done a
good job to help focus on grave problems that beset health system
in India. These groups have either implicitly or explicitly criti­
cised the system for -its excessive biases for s (1) curative medi­
cine, (2) hospital-based health care, (3) cities, (4) the rich and
powerful sections in the cities, (5) disease pattern predominant in
the West, and in a tiny fraction of the population in India.
The logical compulsions arising from such damning critique are
now pushing these groups to move foreward, extend their role into the
uncharted territory of alternatives to present health system whose one
subset is medical education. Let there be no misunderstanding here
that those who discuss critically the present medical education and
alternatives to it are under obligation to run a medical college based
on different objectives, values, curriculum and methods. This is a
false alternative; it can lead to inaction.

However, the groups themselves have to respond intelligently and
sensibly to basic issues of ill health in society discussed in this
note.
It is through continuing analysis and actions of various groups
on atleast some of these problems in similar perspective that relevant
durable, and realistic pieces of knowledge are going to be built.
Without such necessary ground work even a crude prototype of relevant
alternative medical education is not feasible.
At this point we would like to direct a searchlight of criti-cism on ourselves.
We all know that medical colleges as institutions are far too
rigid and too bogged-down in quagmire of unhealthy values, wrong pri-orities and practices to give a new lead. To expect them qua
institutions to initiate relevant changes away from such tendencies
is unrealistic at the moment. What has been the performance of volu­
ntary health groups in this regard ?
Two broad responses can be discrened. One response has consitstently been to lament the fact that forces generated by a particular
form of social and economic organisation are responsible for this
state of affair. As long as they remain in force, any well meaning
attempt to look for an alternative or to try to evolve one-even if
rudimentary- is bound to fail or to be crushed by the powerful system.
This position has a degree of plausibility when a problem of ill
health of community is seen at .a very broad level and analysed in
terms of categories like gradient of morbidity and mortality along
the social classes, unjust characteristics of economic system mani­
festing itself in income disparities, poor sanitation, poor housing,
poor nutrition...etc., etc.
Its truthfulness is not in question, as
is the truthfulness of monotonous slogan ‘poverty, ignorance, lack of
sanitation, poor housing...1 which we have felt compelled to criti­
cise in the foregoing part of note.
Second response has been to take certain health activities in
the fields. The common elements of such efforts are broadly as
follows 2 (1) They WOrk mainly amongst rural poor, (2) they have a
team of village health workers, (3) they carry out activities like a) immunisation of children and pregnant women, (b) run ante-natal &
under 5 clinics and (c) do health education. Now there is nothing
objectionable against these elements of activities perse. Doubtlessly
they are the steps in the right direction.
The real problem does not lie in actual activities but lies in
the theoretical understanding of complexity of disease processes in
the community that inform these activities. Even more pertinent point

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of view is whether the understanding of diseases considered insufficient
and therefore in need of continual improvement which can be done only by
conscious development of abilities and competence in the methods of —
community health.

Voluntary groups are under obligation to learn new methods and
tools to further extend and develop relevant, useful and durable knowle­
dge of diseases in the community. Whatever are the restrictions of the
system it does provide enough scope to develop such actions. The trouble
seems to lie somewhere else? voluntary groups are by and large tied down
by their own training (this we have discussed at length above) and have
also accepted uncritically the notions such as ’most of the diseases are
simple and can be treated easily.1 The 1 felt need’ of voluntary health
groups excludes these methods and tools. The result is only growth of
mechanical, lifeless structures of activities and flourishingof stereo­
types without any insight or understanding. The uncritical acceptance of
notions such as 'diseases are simple....’ which themselves are product
of the ideology of ’ill health in man in hospital’ have pushed them if
unwittingly into extending outpatient to door-stops of individuals.
The criticism which applies to the structure, the content and the
methods of teaching of community medicine in medical colleges applies to
voluntary efforts also, if with diminished force.
The glaring gaps in knowledge, the blind spots in epidemiology of
diseases, as they are found in our situation, the methods of translating
this knowledge into useful health activities, knowing the society and
social processes which affect the acceptance or rejection of such health
activities await serious exploration and trials on a large scale.

Only in this context we say to ourselves s it is not enough to
interprete and criticise the health system as it is today; the point
is to change it.

Speaking of change brings us to second point of concluding part
of the note.
B) THE ROLE OF MEDICAL EDUCATION IN CHANGE OF COMMUNITY HEALTH.

Improvement in the health of society is a function of understan­
ding of diseases in community and social action informed by this under­
standing. We believe the role of medical education is to develop such
understanding. It cannot be a substitute for social action.

Chadwick* s sanitary revolution in mid 19th Century in England is
a classical example of this combination.
By mounting systematic nationwide studies, Chadwick produced a
massive indictment of working population’s sanitary conditions in a book
known as ’The Sanitary Conditions of the Labouring Population (1842)’.
Advent of cholera epidemic in Europe from India created a lot of appre­
hension in Europe. Doctors began to connect ill health more specifically
with pollution of environment (this was at a time when the discovery of
germs still lay in future. The evidence was only epidemiological.)
There was a growing consciousness and demand from public for public
measures of control. Chadwick was able to marshall these forces which
ultimately culminated in Chadwick’s Public Health Act (1848), which
ushered in sanitary revolution in England.
PREPARED BY s

Ashvin Patel and Anil Patel,
Action Research in Community Health,
Mangrol, Tai" Rajpipla, Gujarat,
PINs 393 150.

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