Assimilative healthcare needed for better access

It would be apt to quote Sjaak Van der Geest to set the context of this article, “Interdisciplinarity only has a chance if those who belong to the cultures of social science and those of the culture of medicine give up their ethnocentric fear of dissenting beliefs and accept the practical consequences of the conviction that reality itself is multidisciplinary.”

Advertisement

It is intriguing to note how the definition of health has transfigured over the past century. A dictionary picked up from somewhere in the 1940s will reveal a purely biomedical definition of health that is pivoted around physical health. Nearly eight decades later, every veridical textbook on health has come to enshrine a holistic definition of it that also embraces the mental, social and spiritual dimensions of health. This signifies a movement from the obvious and intuitive to the more subtle and profound. But while the latter is an enlightening recent accretion, it can’t be denied that physical health remains the most primeval, inalienable element that strongly and fundamentally captures anyone’s imagination of health. This shift in perspectives has also reflected strongly in the way healthcare and public health has evolved since the 1950s.

A number of developed countries had at least rudimentarily conceived universal healthcare systems before the 1950s. However, it is hard to come by any prominent enunciation of the principles that are indispensable to healthcare today, such as inter-sectoral coordination and community participation, before the 1960s. It was the wave of decolonisation, the changing perspectives on development, and the increasing awareness of the peculiar needs of developing countries that cemented these principles in the global health discourse as pivotal elements of what came to be known as “comprehensive primary healthcare” in the 1970s.

Public health has undergone a concurrent and similar transition. Public health has traditionally been mainly about physicians and ancillary medical staff delving either part-time or full-time in improvement of population health. A prominent role for medical anthropologists and social scientists in public health only came to be acknowledged after the 1980s. Today, public health has rightly been recognised as a multi-disciplinary endeavour, though much more remains to be done here. Unfortunately, there are signs today that some parts of the public health fraternity have gone overboard with this to resentfully minimise the role of biomedicine in public health. This is unwelcome.

Such signs have emanated from some of the humanities-based public health academia that has rightfully gained some space in the past few decades. The first World Medical Education Conference in 1953 and the subsequent national proceedings led to the creation of ‘preventive and social medicine’as a separate medical discipline that is wrongly assumed by some to be synonymous with public health. Following the increasing recognition of the significance of multidisciplinary public health, an expert committee in 1996 recommended that more public health schools be opened in the country. What followed was an increasing number of institutions that offered Master of Public Health (MPH) courses. While a majority of these institutions have ramified from the erstwhile medical colleges or medically-oriented bodies, some of them have branched off from the humanities and social sciences. Spurred by the traditional hegemony of biomedicine and its wrongful disdain of the social sciences — a subtle counterculture that rancorously dismisses the role of physicians seems to be emerging today.

Lest it be misconstrued — let us note that a lot remains to be done to moderate the undue hegemony of medicine in Indian public health. And a rebellion and reassertion of the social sciences against this hegemony is not only natural but also warranted. However, to interpret this to depict biomedicine as any less relevant than a central pillar of public health is unwarranted. The breadth of mutual dependency and dovetailing between biomedicine and public health, and their common origins and parallel evolution, are features that public health has hardly shared with any other allied discipline, be it engineering or even the social sciences. While critics often rightfully assert that the realms of population health (addressed through public health interventions) and individual health (addressed through healthcare) are distinct, the inexorable connections between them are unassailable and fundamental to any coherent ideation of health. For some to go overboard and appropriate public health from biomedicine is an unwarranted development at a time when the country is only beginning to truly appreciate public health’s truly multidisciplinary character.

This going overboard with the enthusiasm for multidisciplinarity has also reflected in the production of MPH graduates in the country. That MPH programmes should rightfully be open to candidates from diverse educational backgrounds has meant that scarce attention has gone into ensuring a right mix of aspirants. It has been overlooked that while public health is multidisciplinary, MPH candidates with different educational backgrounds are not always mutual substitutes. Today, in the absence of enough popularity with MBBS doctors, dental and AYUSH graduates form a large majority of MPH aspirants. Coupled with a lack of workforce planning, this has meant that a large majority of MPH graduates are continually employed in disparate jobs that have little to do with public health targets.

It is time that every quarter of the public health fraternity unites in upholding the truly ‘multidisciplinary’ spirit of public health. It is important to appreciate the unique role and importance of each category of public health professional without resorting to any partisan interests whatsoever. For much of the foreseeable future and in a pragmatic sense, the public health professional with a medical background is likely to continue being at the forefront of public health. Concerted efforts to mainstream public health in undergraduate and postgraduate medical education is far more in the interest of Indian public health than pedantically drawing divides between them.