Community-based Medicine

From Classrooms to Neighborhoods -- A Reality Students Must Be Prepared For

Alejandro Avelino Bonilla

In recent decades, medical education has been changing around the world in an effort to improve quality, equity, and relevance among other characteristics. A good example for this is the accreditation process of many medical institutions around the world. Besides this, institutions are also aiming to reach what has been defined as social accountability, and it is the main topic of the must-read, “Global Consensus for Social Accountability of Medical Schools.” ¹ Both topics have been widely explored by The Network: TUFH and its members during the last years and are reflected on The Fortaleza Declaration (2014)² and the Tunis Declaration (2017)³ seeking global learning objectives for health professionals and to enhance health and social justice in the social accountability context respectively.  

Accreditation and social accountability are topics that deserve their own review and discussion, but both are related to an issue I want to highlight, the disparity between what is taught and learned during the undergraduate period and what is really useful and needed to work with, and in, communities. From the accreditation perspective, standards are given in order to develop programs and activities in the communities (depending on the national standard that is widely used), meaning that students will, for sure, be in touch with the communities and their surroundings in non-clinical or outreach activities. On the other hand, social accountability has a much bigger picture of the community and includes relevance, quality, cost-effectiveness, and equity to the activities developed in the community.^4,5 

We, as health educators, talk about the relevance of community-based practices and that students must be in touch with the community (even though some students and even teachers may be slightly against it), but community-based practices are not the same as socially accountable actions, neither being a social accountability program. Therefore, students are being taken to communities to perform activities, within accreditation standards, but they might not be socially accountable and it endangers the development of health care students and the reason is quite simple, during and around four to seven years, health care education institutions train students to face and treat health issues in a clinical context (of course this does not apply to all medical institutions but for most it does), and then, they are taken to a more social context where they do not have the tools and environment they are used to, so they must face a completely new reality. This situation can be so deeply entrenched that even the country's health system is not designed to respond to the needs of the community outside the hospital, so what do we expect from students when it comes to commitment and delivery within the community? Why do we proudly say that our students perform activities in the community when we are not really having the desired effect on them nor on the community? Or at least in most communities because even faced with these difficulties, some students actually “fall in love” with the community’s health and that’s what brings us to this discussion. 

Recently in Latin America there was a debate about the voluntary interruption of pregnancy as a right, Argentina⁶ and Colombia⁷ just to cite some examples, and many institutions refused to train their students about this type of care. In the specific case of Colombia when the students where asked, many reported that they received little or almost no training about the topic. If this happens with a subject that is specific, what might be happening when we try to teach and inform students around health in the communities, and even more complex, social accountability issues?

Now, from the community context, are they involved in the planning, execution, and follow up of these community-based practices or social accountable activities? Do we even ask them what they need and what is a priority for them? Or do we just assume that we know what is best because we are the health professionals? A highly involved and active community is not a common thing but is not impossible to find or to nurture. Yet it does require time and work and once it is archived, it can basically guarantee the sustainability part of the impact of the intervention. This brings us to the “the elephant in the room,” are we involving the community? Are we working for the community, in the community, or with the community? Most of the community-based activities tend to be focused on building capacities for the students, but not all of them aim for building capacities for the community as well. These activities ended up being used as a means to reach the objectives with the students, instead of being the end itself and forming students along the way.

So, if we combine these factors, students are being formed on a clinical level and then taken to perform community-based practices that do not meet the needs of the community, ultimately we will have newly graduated doctors that do not possess the theoretical and practical knowledge to answer a community’s health needs, and additionally, communities that do not feel like they can identify with these newly graduated doctors. Isn’t this a problem we are facing worldwide? Of course, it has other contributing causes, but this is one we can face now.

The solution can be found in the problem itself once we face it. Building programs and curriculums around the needs of the community -- with the community -- will allow students to face these needs in a much more real scenario, while during classes students will receive education in primary health care. This is a solution that does not require additional funding, it requires a restructuring and prioritization, something that is extensively addressed during the actions of primary health care and community-based primary health care.

There are many programs and institutions that are changing the health related education paradigm and that we all can meet in the next The Network: TUFH Social Accountability: From Evidence to Action Conference in Darwin, Australia, which demands that institutions, teachers, students, and policymakers among others participate in this must attend event.

This is just a short reflection on a subject that requires a wide and rich debate with different perspectives to support primary health care as a reality that will last over time and that will deliver the impact we are looking for -- education and health promotion, disease prevention, early detection and treatment, and the improvement of the quality of life of the entire population. It may sound idealistic, but Ayn Rand stated it best, “Anyone who fights for the future, lives in it today.”


Works Cited

• Abdalla, Mohamed Elhassan, y Charles Boelen. “Social Accountability of Medical Schools: The New Frontier For Development”, 2012, 7–31.
• Awases, Magdalena, Rebecca Bailey, Charles Boelen, y Mario Dal Poz. “Global consensus on social accountability of medical schools”. Sante publique (Vandoeuvre-les-Nancy, France) 23, núm. 3 (2010): 247–50. www.ncbi.nlm.nih.gov/pubmed/21896218.
• Boelen, Charles, Jeffery E Heck, y World Health Organization. Division of Development of Human Resources for Health. “Defining and measuring the social accountability of medical schools”, 1995. apps.who.int//iris/handle/10665/59441.
• Cañón, Laura Natalia Cruz. “Facultades de medicina, reprobadas en Interrupción Voluntaria del Embarazo”. El Espectador. 2019. www.elespectador.com/noticias/salud/.
• Garcia, Glenn. “Abortion in Argentina”. The Lancet 393, núm. 10173 (2019): 744. doi.org/10.1016/s0140-6736(18)32767-3.
• Goñi, Uki. “‘Thousands’ of young girls denied abortion after rape in Argentina”. THe Guardian, 2019. www.theguardian.com/global-development/.
• Members of The Network; TUFH. “The Fortaleza Declaration”. Fortaleza, Brasil, 2014. thenetworktufh.org/declarations/.
• ———. “Tunis Declaration”. Hammamet, Tunisia, 2017. thenetworktufh.org/declarations/.

 
 
 
Footnotes

 

• ¹ Magdalena Awases et al., “Global consensus on social accountability of medical schools”, Sante publique (Vandoeuvre-les-Nancy, France) 23, núm. 3 (2010): 247–50, www.ncbi.nlm.nih.gov/pubmed/21896218.
• ² Members of The Network; TUFH, “The Fortaleza Declaration” (Fortaleza, Brasil, 2014), thenetworktufh.org/declarations/.
• ³ Members of The Network; TUFH, “Tunis Declaration” (Hammamet, Tunisia, 2017), thenetworktufh.org/declarations/.
• ⁴ Charles Boelen, Jeffery E Heck, y World Health Organization. Division of Development of Human Resources for Health, “Defining and measuring the social accountability of medical schools”, 1995, apps.who.int//iris/handle/10665/59441.
• ⁵ Mohamed Elhassan Abdalla y Charles Boelen, “Social Accountability of Medical Schools: The New Frontier For Development”, 2012, 7–31.
• ⁶ Glenn Garcia, “Abortion in Argentina”, The Lancet 393, núm. 10173 (2019): 744, https://doi.org/10.1016/s0140-6736(18)32767-3; Uki Goñi, “‘Thousands’ of young girls denied abortion after rape in Argentina”, THe Guardian, 2019, www.theguardian.com/global-development/2019/mar/05/.
• ⁷ Laura Natalia Cruz Cañón, “Facultades de medicina, reprobadas en Interrupción Voluntaria del Embarazo”, El Espectador, 2019, www.elespectador.com/noticias/salud/.

* Alejandro Avelino Bonilla is a physician and epidemiology postgraduate student from Juan N. Corpas University in Bogotá, Colombia. He is a National Research Leader in the Colombian Medical Student Association ACOME and member of the advisory board of The Network: TUFH. For more than three years he was a student representative for his University, as well as founder and co-president of the Colombian Association of Students Representatives of Higher Education ACREES. Alejandro also previously served as a Latin Americas´ representative and president of SNO.