Self-designed major: community/public health

I have just responded to yet another request to meet with a student who wants to design a major in public or community health.  This will bring to more than a dozen the number of students I’ve talked with in the past year about these prospects, and I have the impression that this number will double before the end of the current academic year.  For the most part, students are encouraged to contact me by our remarkable pre-med advisor, Dr. Bev Sher.

I’m a little unsettled by the trend, not least because I am a criminologist.  That is to say, I need to make clear to readers as I do to those students who come to talk about public health issues that I am not an expert in medicine or health.  Fortunately, students interested in this self-designed major get excellent advise from Dr. Sher.  My interests concern the matters of “public” and “community,” and I want to consider those briefly in the context of what I hear from (mostly) pre-med students who want “something more.” I’ll return to these issues in just a minute.

My colleague (Mark Ryan, M.D., co-conspirator in SOMOS and SHC — described elsewhere in my blogs — and W&M alumnus) and I recently presented a paper at the annual meetings of the American Association of Family Medicine.  The topic was, essentially, “where’s the community in Community-Oriented Primary Care?”  My review of the research literature (especially within the field of public health) on Community-Oriented Primary Care (C-OPC) suggests that most such projects treat the community as a “convenient aggregate”  — that is, a population, a location, a collection of patients with some common attributes, or the like.  As a social scientist, I want to argue that communities are real (see an earlier blog, called not so surprisingly “Communities Are Real”).  This is not an abstract academic point to me.  Indeed, my premise is that effectively improving health and health care requires understanding and partnering with the arrangements, associations, and resources that comprise a community.  My medical colleague and friend, Dr. Ryan, agrees at least enough to want to join the argument to take seriously the social realities that likely will influence strongly the prospects for success for efforts that go beyond conventional medical, clinical, or private practice medical care.

Students interested in a self-designed major come wanting to do “more than” conventional private practice, hospital, or clinical medicine.  They often are not entirely clear what that “more than” is, though they point frequently to public health, community medical care, and international outreach as possibilities.  Keeping in mind that I come to this conversation somewhat sideways, I want to make a few observations.  Based on my reading, conversations with those trained in public health, and my consideration of various M.P.H. programs, I see several important variables:

• Some M.P.H. and undergraduate public health programs focus on epidemiology as the core issue for improving health and the quality of health care
• Some academic programs in public health focus on administration, aiming to prepare physicians and administrators to work in public health programs and facilities
• Some public health education programs are oriented principally to policy (espcially, resarch and development of policy alternatives)
• Not so many public/community health programs seem oriented to the basic social science of communities or to strategies that take seriously the empirical and consequential realities of social structure and culture

I cannot say what moves so many of our students to want preparation beyond the pre-med curriculum as they move towards medical school.  I suspect that some do not find the standard curriculum sufficiently in touch with “human” concerns and considerations.  I suspect that some are suspicious of “business as usual” strategies that lead from undergraduate “science” courses to medical school to medical practice, worrying that doing as we have been for so long will not lead to different or better results for underserved and unserved populations.  I have seen direct evidence that some of those who come to my office appreciate social and cultural realities and have some sense of need to take these into account as they prepare to make their contributions to better health.

My abiding hope is that some (many?) will come to appreciate that “community-oriented” health programs offer great promise for long-term and sustainable improvements in health and health care.