By Sandra Albert
People often ask what is the difference between Public Health (PH) and medicine? What is the difference between a Public Health professional and a doctor in a hospital? Now, in the midst of Covid-19, is perhaps an opportune moment to check out the difference.
At a broad level the key difference is that PH addresses health at the population level unlike clinical medicine which often deals with health at an individual level. For instance, doctors, physiotherapists, dentists deal with individual patients daily and solve problems at the individual level. PH on the other hand looks at groups of people, both the sick and well people. Groups could be at a community level, a country or at the global level.
Medicine is just one of the subjects in the multidisciplinary field of PH. During the Covid-19 pandemic people went to hospital for treatment when they got very sick with fever, cough and breathlessness or the ‘severe acute respiratory illness.’ This severe form of illness required a hospital and a heath care team such as nurses, doctors and allied health personnel. But before someone falls seriously ill, there is much that can be done by way of prevention at the community level. Thus, the rest of the activities involving disease surveillance, screening, contact tracing, public health policies, guidelines, health communication, disease modelling for planning, appropriate testing strategy, sensitivity and specificity of tests, health system strengthening involves PH rather than pure medicine.
Epidemiology and biostatistics – core subjects
To answer questions like – Has community transmission taken place and what is the magnitude of the disease in our country? We require prevalence studies to be done and estimates to be made. Or is there any difference between different groups (e.g. by geography, ethnicities, socio-economic status). Designing and executing such studies come under the remit of epidemiology and biostatistics two fundamental pillars of PH education.
The purpose of much PH research is to understand what causes a disease? For instance why do some people get more cancers? Does ‘exposure’ to anything in particular increase the chances or ‘risk’ of getting a disease, the ‘outcome’? To help us understand what causes a condition, PH research looks at risk factors in the context of ‘exposures’ and ‘outcomes’. In Covid-19 it is the virus but how much of exposure is required to make one get the disease. Just casually walking past a person with the virus is unlikely to put one at much risk but close interaction with an infected person for more than 15 minutes puts one at higher risk of getting the infection.
What do PH professionals do?
In simple terms they gather or create evidence and they help plan actions that will improve the health of the community. Once they have some evidence, the next step is to plan interventions or programmes to improve health. The first aim of planned actions is directed towards keeping healthy people as healthy as possible by preventing diseases by promoting behavioral change and encouraging good ones like exercise while discouraging poor ones like smoking.
To date there is no ‘magic bullet’ to cure Covid-19. But we can definitely prevent ourselves form getting it if we and others attempt behavioral changes e.g. hand washing, wearing masks and coughing etiquette. By these actions we also reduce our exposure to risk. Risk factors become more complex to understand when we deal with non-infectious conditions like cancers. There are also other risk factors that need to be considered for instance social determinant of health – are the poor more likely to be at risk?
The second aim is to ensure that those who are unwell have access to care and treatment. Advocacy involves using evidence for policy change to ensure equitable access to safe and effective treatments. For this a functioning health-care system has to be in place to provide care and treatments.
PH is Multidisciplinary
PH is multidisciplinary: PH policy, PH economists, PH nutritionists, PH educators, health analysts, mathematical modelling, PH sanitation, PH engineering, PH law, are all disciplines. Resources are always scare especially in a country like India that spends less than 2% of its GDP on health (Germany, Sweden, Netherland all>11%, Thailand 3.7%). Health economists do cost effective analysis to help us prioritize and make best use of scarce resources. For example; which test is more cost effective? How much and at what levels should these be done?
Optimal PH actions require trained personnel or people with the skill sets and attitude to do the job. Should doctors alone be in charge of PH of a state? An MBBS degree does expose you to some concepts of PH but in a superficial manner. Someone who had driven a Maruti 800 all her life, if now given the keys to a brand-new Ferrari, will possibly inch it forwards gingerly or be at high risk of causing an accident. This is why we seek out a cardiologists when we have a heart problem not a gynecologist – although all have basic medical skills. This is also why the National Health Policy 2017 clause 11.8 “proposes creation of Public Health Management Cadre in all States based on public health or related disciplines, as an entry criteria. Medical and health professionals would form a major part of this, but professionals coming in from diverse backgrounds such as Sociology, Economics, Anthropology, Nursing, hospital management, communications, etc. who have since undergone public health management training”.
The efficiency of a health system often depends on trained personnel managing different aspects of public health such as health service planning, governance, leadership and information management. European countries have a department that looks into ‘health in all policies’, in other words any new policies made by any government department will have to take into consideration the public health implications of the policy.
A Public Health Sciences University
In the northeast there is a tendency to attribute poor health indices to shortage of medical colleges. But good health has little correlation with number of medical colleges. A key rationale offered for establishing medical colleges is to address doctor ‘shortage.’ But as of now there is seemingly little shortage of MBBS doctors in Meghalaya; most of the over 500 posts in the State Health Department are filled. What Meghalaya lacks are specialist doctors, like obstetricians, surgeons, anesthetists and pediatricians (over 50% of the sanctioned posts are lying unfilled). Mere setting up an additional medical college/s will not address the deficit of specialists even in the next 30 years. Instead we need to look at alternate models – as done by some states by converting large district hospitals into postgraduate training centers for specialists as is being considered by Meghalaya.
Setting up a medical college is an expensive venture, requiring initial capital expenditure of Rs 300-500 crore. This amount can raised from banks willing to extend soft loans. What is of concern is the annual recurring or operational expenditure. Sustaining a medical college can cost Rs 80-100 crore annually. In states that have barely enough funds to sustain their health budgets, this is an issue worth pondering, especially when northeast states rely on the Centre for nearly 90% of their health budgets (through NHM) and lack of funds for local health initiatives is a common problem that health departments face. The emphasis must be on prevention and primary care rather than the more ‘glamorous’ tertiary care.
The State Government’s initiative in enabling the setting up of the Indian Institute of Public Health (IIPH) in Shillong was a visionary move. With this a small but significant start has been made. The need of the hour is to provide such institutions facilities and funding to substantially ramp up training. This is a necessity as Covid is not the only outbreak we are dealing with. Almost every year there are outbreaks of swine flu, Japanese encephalitis, scrub typhus, typhoid and brucellosis (often reported as mystery diseases in the press).
The IIPH Shillong is currently training doctors, nurses and allied health personnel from Meghalaya and other northeast states though a Master of Public Health (MPH) programme. Their plans to offer new courses, expand infectious diseases research laboratory and other facilities are being hampered for want of space. In the past other disciplines like fashion technology and Hotel Management have been prioritized over public health. Hopefully that will change post Covid-19.
A doctor who is also an MPH student at IIPH Shillong called me this morning for an informal discussion on challenges they are facing at the Corona Care Centers in Shillong. She had this to say, “Before my MPH training, my focus would only have been on somehow managing patients and sending them home. But now I am constantly thinking, ‘why is that happening, what is a better solution? How can it be managed better to prevent further infections? Is there a health system issue here?” A public health sciences university would cost a tiny fraction of the cost of a medical college, but in the long term it has the potential to give enormous health dividends to the state.
(Prof Sandra Albert is Director, Indian Institute of Public Health Shillong)