Journalists against TB welcomes guest writer Dr. N. Devadasan, MBBS, MPH, Director, Institute of Public Health, Bangalore. He has written a very insightful piece on what public health should encompass. We are honoured to have him contribute to our blog.
Public Health – what does it include?
“Who or what is a public health specialist?” This is a question that I am regularly asked by lay people. They have heard of obstetricians, paediatricians, neuro-surgeons, but not public health!!!! I usually use my friend Arvind Kasturi’s (Head of Department of Community Medicine, St John’s Medical College, Bangalore) response to explain – “most other doctors treat individual patients; but we public health specialists treat populations”. That shuts them up long enough for me to escape.
Jokes aside, what is public health? In India and in many other countries, public health is synonymous with preventive medicine. In medical and nursing schools, public health (or community medicine as it is known) is synonymous with rural areas; dimensions of pit latrines; chlorination of wells, government health programmes like immunisation, antenatal care and leprosy control. It is small wonder then that most starry eyed medical students who want to “cut” or “diagnose rare diseases” are put off by community medicine.
Even in government health services or among bilateral and multilateral donors, public health is about organising preventive services for reproductive and child health (RCH), or TB. Public health professionals are very easily asked to evaluate a mental health programme; but not the quality of care provided in a hospital. This is because quality of care in a hospital is seen as curative (or clinical medicine) and not in the domain of public health.
However, I was taught what public health is, by the adivasis (tribal people) of Gudalur, Nilgiris, Tamil Nadu. My wife Roopa and I spent ten years with them, and got lots of pearls of wisdom. One of this was the insight into public health. Fresh from Christian Medical College (CMC),Vellore, we also believed that public health was about prevention. So we would visit these remote villages and spout out our knowledge about immunisation, about the need for antenatal check-ups, about the importance of safe drinking water etc. Till at one village meeting, an adivasi woman asked us very gently, “Sir, you tell us to immunise our children. We believe in you and we come with our children for the injections. However, when our child has cough and cold, you tell us to go to the government hospital because these diseases are not prevented by immunisation and need to be treated by different doctors. Why is this? If you can prevent some diseases, why cannot you treat other diseases? Are you not a healer?”
That shook the very foundation of our concepts on preventive and curative care. We realised that this is a very artificial divide; a construct developed by us medical professionals. For the community and the patient, this divide is immaterial. They see the doctor or the health professional as somebody who will alleviate their suffering and will solve their health problems. For them it is a continuum; the doctor is responsible for looking after the pregnant woman (antenatal check-up which is preventive care); conducting the delivery and ensuring a safe mother and child (delivery which in our jargon is curative care); preventing the child from getting diseases (immunisation which is preventive care) and treating the child when it has illnesses (curative care). That is when we realised that public health encompasses all of this.
This was further reinforced when we went for our MPH at Institute of Tropical Health, Antwerp, Belgium. Case studies from most other countries showed that their health staff (especially at the primary health centres) provided this comprehensive care – both preventive and curative. Obviously we in India had got it wrong. To give further examples:
Good housing is an example of Health Promotion for TB
BCG is preventing TB
Early diagnosis and treatment of TB is curative but can also be considered prevention of complications and MDR TB
Treatment of MDR TB is curative, but can be also considered as prevention of spread of MDR TB and death
Way back in 1978, the Alma Ata declaration talks about treatment and referral services in primary health care. However, these were conveniently put aside and we concentrated only on prevention. So basically we in India have artificially divided health care into preventive and curative medicine.
After all these experiences, we realised that public health is about protecting and ensuring the health of the public. This ranges from talking about healthy lifestyles; to preventing diseases; to curing illnesses when they occur; to rehabilitating people with disability. Thus public health is as much about developing effective health messages as about ensuring that hospitals are providing quality referral services. It is as much about organising immunisation campaigns as about ensuring that diabetic patients are provided care that is holistic and continuous. It is as much about monitoring maternal deaths as about financing the health system to make it affordable to the community. It is as much about listening to the voice of the people through community participation as taking this voice to the highest level of policy making. Public health is about safeguarding the health of the population, about comprehensive care, about care that encompasses the entire spectrum of promotive, preventive, curative and rehabilitative care.
Dr N Devadasan
The views expressed here are entirely of the author