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# Teaching Public Health in Medical Schools: A New Public Health Leadership by Prawase Wasi, M.D. Professor of Medicine Emeritus Mahidol University, Thailand A key-note paper for the "WHO/SEARO Regional Meeting on Teaching Public Health in Medical Schools" 8-10 December 2009, Bangkok, Thailand The present world crisis cannot be solved short of changing the objective of mankind. Long ago, Albert Einstein said, "We shall need a radically new manner of thinking, if mankind is to survive". The present crisis is a crisis for the survival of mankind and the planet. Profit - driven development has led to social and environmental disintegration. One way to look at "a radically new manner of thinking" is to change the objective of mankind "From Profit to Health". Health is the whole. Health is integral in total human and social development. Any compartmentalized development will disturb the whole or health. For survival of mankind, a new thinking demands a paradigm shift from profit to health. Public health should be the Sumum Bonum of mankind. With this it follows that there is a great need to develop public health consciousness and leadership to steer the world toward this new goal. Public health should be looked at in a new manner. Public health is not only concerned with infectious disease epidemics and clean water. Although those components remain important, New Public Health is much more than that. Since health is the whole, health means a complete well being: physically, mentally, socially, and spiritually. Good health must precede ill health. Prevention is much better and cheaper than cure. Health promotion must deal with determinants outside the usual public health sphere. It is said that 80 percent of good health determinants lie outside the usual public health boundaries. Issues like poverty eradication, education, culture, environment, community strengthening and public policies are very relevant to good health. New public health demands new leadership, and medical doctors should meet this challenge. Medical care is in crisis all over the world. Advancement in medical technology brings a very difficult dilemma. On one hand, advances improve diagnostic and therapeutic measures, sometime to a miraculous level, which increases demand, either genuinely or falsely. On the other hand, the costs of new technologies are sky high, driving dramatic increases in health care expenditures to the brink of impossibility. In the United States, health care expenditure has increased to 16 percent of the GDP, the highest in the world both proportionally and in real terms. Yet, 40 million Americans are without health insurance coverage of any kind. This is a clear case of a non cost-effective system. High costs of technologies are leading to inequity in health care. The same pattern is occurring in every country. The high cost of medical care is depriving the poor of the opportunity of good health. Medical doctors should provide leadership in health care reform for a more cost - effective system. It is a moral obligation for medical schools and medical doctors to be leaders in making good health for all possible. Every doctor should be a new public health leader. Attempts were made to teach public health to medical students from the beginning. The early form of the medical school was not much separated from public health. In those days, it was almost automatic that most doctors did public Public Health is the Sumum Bonum of Mankind Public Health Consciousness and Leadership The Medical Care Crisis Teaching Public Health in the Medical School in Changing Situations 2 health work. In time, public health and medical education have become increasingly separated. More and more, medical school hospitals are highly specialised in tertiary medical care with sophisticated technologies, and with less and less interest in public health. Medical students being trained in this kind of atmosphere lose their instinct for public health. Various attempts have been carried out to rescue the situation. Departments of Preventive and Social Medicine were set up in the medical schools. Later, a community health curriculum was introduced. In the early 1980s, spear – headed by the Rockefeller Foundation, clinical epidemiology as an academic discipline was introduced in various medical schools around the world in order to transform one – to – one care to population – based medicine. Within the grip of the increasingly sophisticated tertiary care in the university hospitals, all the above mentioned attempts have not had much success in restoring public health leadership among future doctors. A new paradigm of medical education is needed. As the atmosphere of university hospitals is more suitable for post – graduate medical training, undergraduate medical education should be re – designed, and its base should be relocated. A New Paradigm of Medical Education As the health care crisis is real and has encompassing effects, health systems reform should be a national priority. Universities must play active roles in this national health systems reform. Medical education should have a prominent role, or even better, a leading role in national health systems reform. To curb the rapidly rising cost of medical care, medical schools should try to increase quality care at lower cost. This requires a new consciousness and new skills. Clinical teachers must be aware of the national situation and apply clinical economical skill. A new science of clinical decision analysis should be developed. In prescribing diagnostic investigations and therapeutic measures the clinical teachers should compare the costs and the effects of those measures and carry out the best cost – effective choices. This will be very scientific because in being able to do clinical decision analysis, clinical teachers must be well-versed in epidemiological data and possess the knowledge of specificity and sensitivity of the technologies being considered. If the clinical teachers practice clinical decision analysis in their patient care, this will automatically create new culture and new scientific clinical skill. Together they will send reverberations throughout the patient care system, leading to a more cost – effective health care. Another and more plausible measure to cut cost and improve quality of care is to develop a good community health system. A good community health system is much more cost – effective than the large hospital – based system. The community health system includes self care, family care and community care. It has at least 7 objectives: (1) Take care that no one is without care in the community. (2) Promote sufficiency economy. (3) Take care of all common illnesses. (4) Control diabetes and hypertension. (5) Take care of the aged at home by home visiting nurses. (6) Control diseases. and (7) Health promotion. A well-functioning community health system will promote good health to the maximum and care for most of the common illnesses, thus cutting down a great number of unnecessary visits to big, expensive hospitals, allowing them to increase quality care. Thus, a good community health system plays a vital role in health care reform. 3 The community hospital is at the strategic center of the community health system. Doctors at the community hospitals, contrary to the medical specialists in the big hospitals, have system perspectives and managerial skill. They are more likely to understand policy dimensions, not just technical ones, and therefore can assume new health leadership roles. For new health development, there is a need for future doctors to be able to assume health leadership roles. The tertiary medical care - based atmosphere cannot cultivate new health leadership. The medical schools cannot and should not avoid the role of developing future new health leaders. This is why the medical schools should work with the community hospitals. The medical schools should help strengthening the community hospitals and **The Community Hospital Medical School** the latter should serve as base for medical students' training. Clinical skills will be acquired at the community hospital more quickly than at the tertiary hospital. Moreover, a more comprehensive care can be practiced at the community hospital. Medical students have plenty of opportunity to carry out research, clinical, epidemiological, and of the health system. They can learn to develop managerial skill as well as to understand policy issues. They will be better prepared at the community hospital to assume new health leadership roles. Linkage between the medical schools and the community hospitals will reorient the medical schools toward wider health perspectives, thus enabling them to take part in health systems research and policy issues. The ability of the medical schools to affect health systems and public policies is very crucial for health systems reform as a whole. A mere public health teaching in the old paradigm of the medical school will not work. There is a need to understand new public health, in which health is not concerned only with diseases, but is integral in total human and social development. Public policies become very crucial for a new health paradigm. New health leadership is required if Health For All is to be realized. The medical schools should meet the challenge of new health leadership roles. If not, they will be part of the health care crisis instead of the solution. The medical schools should try to understand the health care system in crisis and participate in health system reform. A new public health needs a new paradigm of the medical school and medical education. Linkage between the medical schools and the community hospitals in an attempt to develop a good community health system would be a noble beginning. Medical students based in the community hospitals which are strategic points for community health system development will automatically learn public health in a new manner. This new approach in public health learning of the medical students under a collaboration of the medical schools and the community hospitals to develop a good community health system, will have a profound effect on health systems reform for Health For All in the long run. --- 4 PQET A New Public Health Leadership ประเวศ วะสี

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