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WHO Study Group on Social and Preventive Medicine, Manila, Philippines, 16-29 October 1957 : final report

31 декабря 1957 г. Всемирная организация здравоохранения

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WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL , .AND PREVENTIVE MEDICINE Manila,

RIDIONAL OFFICE FUR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./A-7 17 Octobl'lr 1957 ENGLISH ONLY

Philippines 16-29 October 1957

CHECKLIST OF OOCUMENTS DISTRIBUTED TO PARTICIPANTS •

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Document Number WP.RO/SOC.PREV.MED./l Rev.l WPRo/SOC.PREV.MED./2

Title TENTATIVE AGENDA RELATIONS BEI'WEEN THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE AND OTHER DEPARTMENTS OF THE MEDICAL SCHOOL by Dr. H. lara THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE. THE CURRICULUM. By Professor E. Ford

Available in English (E) and French (F E & F.

E & F

WPRO/SOC.PREV.MED./3

E & F

WPRO/SOC.PREV.MED./4

ROLE OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE IN COMMUNITY HEALTH ACTIVITIES by Dr. Chia-chi Ma. THE SCOPE OF RESEARCH IN SOCIAL MEDICINE by Dr. AlWyn Smith

E&F

WPRO/SOC.PREV.MED./5 WPRO/SOC.PREV.MED./6

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ORGANIZATION OF DEPARTMENT OF PREVENTIVE AND SOCIAL MEDICINE by Professor E. Ford THE PlACE OF SOCIAL MEDICINE IN UNDERGRADUATE MEDICAL EDUCATION. ·by Professor E.S. Monteiro and Professor T.A. Lloyd Davies

~O/SOC.PREV.MED./7

E&F

WPRO/SOC.PREV.MED./8

TEACHING OF SOCIAL AND PREVENTIVE MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS IN THE REPUBLIC OF KOREA. by Dr. Choo-Wan Myung and Dr. Sang Whang Shim TEACHING OF SOCIAL AND PREVENTIVE MEDICINE FUR UNDERGRADUATE MEDICAL STUDENTS IN THE PHILIPPINES by Drs. M. Aycardo, H. Lara, V. Ramos and A.G.M. Sison COMPLETED QUESTIONNAIRE ON THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS

E&F

WPR~/SOC.PREV.MED./9

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WPRO/SOC.PREV.MED./I0 WPRO/SOC.PREV.MED./I0 Annex I WPRO!SOC.PREV.MED.!lO Annex II WPRO!SOC.PREV.MED.!lO Add.l WPRO/SOC.PREV.14ED./10 Add.2 WPRO/SOC.PREV.MED./10 Add.S WPRO!Soc.PREV.MED./lO Add.4 WPRO/SOC.PREV.MED./IO Add.5

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WPRO/SOC.PREV.MED./ll

WPRO/SOC .PREV .MED./A-7 Page 2 Document Number WPRO/SOC.PREV.MED./ll Title -MEDICAL EDUCATION IN COMPLETE MEDICAL CARE by the Committee on the Family Health and Medical Care Programme, Harvard Medical School A PROPOSAL FOR THE TEACHING OF PUBLIC HEALTH AND SOCIAL MEDICINE by Dr. K.J. Mann THE PHYSICIAN IN HEALTH EDUCATION by Dr. G. Rosen COMMENTS ON PRACTICE FACILITIE3 AND COMMUNITY RESEARCH OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE by Dr. John B. Grant DEFINITIONS OBJECTIVES OF THE STUDY GROUP MEETING ON SOCIAL AND PREVENTIVE MEDICINE by the Secretariat A SURVEY OF THE TEACHING OF SOCIAL AND PREVENTIVE MEDICINE IN THE JAPANESE MEDICAL SCHOOLS by Professors Y. Kusa.ma, K. Nobechi and T. Ogata and Assistant Professor H. Katsunuma Available in English (E) and French (F) E &

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WPRO/SOC.PREV.MED./l2

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WPRO/SOC.PREV.MED./l3 WPRO/SOC.PREV.MED./14

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WPRO/SOC.PREV.MED./l5 WPRO/SOC.PREV.MED./l6

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WPRO/SOC.PREV.MED./l7

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*WPRO/SOC.PREV.MED./l8 *WPR0l7:0C'PREV .MED.7~-l WPR SOC.PREV.MED. A-2 *WPRO/SOC.PREV.MED./A-3 WPRO/SOC.PREV .MED./A-4 WPRO/SOC .PREV .MED./A-5 WPRO/SOC.PREV.MED./A-6 WPRO/SOC.FREV.MED./A-7 wPRO/SOC.PREV.MED./A-8 ~PRO/.SOC.PREV.MED./.l9

LIST OF PARTICIPANTS, OBSERVERS AND STAFF PROVISIONAL SCHEDULE ARRANGEMENT OF THE DISCUSSION GROUPS ORGANIZATION AND PROCEDURES OF THE STUDY GROUP

E only E only E only E &

E only CHECKLIST OF DOCUMENTS DISTRIBUTED TO PARTICIPANTS SPECIAL INTEREST GID UPS E&F WPRO/SOC.PREV.MED./IB-l ...

* Please see Page 3

WPRo/ooc .PREV .MEJJ./A-7 Page 3 Available in English (E) and French (F~ E &

Document Number WPRO/OOC .PREV .MED./IB-l WPRO/OOC.PREV.MEJJ./IB-2 WPRO/SOC.PREV.MEJJ./IB-3

Title Information Bulletin No. 1 Information Bulletin No. 2 Information Bulletin No. 3 Information Bulletin No. 4 Information Bulletin No. 5

E only E&F E only E only

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WPRO/SOC.PREV.MEJJ.!IB-4 WPRO/OOC.PREV.MED./IB-5

WFRO/SOC.PREV.MED./18

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ME:MORANDUM FROM THE HARVARD SCHOOL OF PUBLIC HEALTH CONCERNING A ffiOGRAMME OF POSTGRADUATE EDUCATION IN PREVENTIVE MEDICINE AND PUBLIC HE'.AIll'H

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WPRO/SOC.PREV.MED./l9

PROVISIONAL REPORT OF THE WHO STUDY Gro UP ON THE TEACHING OF

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SOCIAL AND PREVENTIVE MEDICINE, HEW IN MANnA, PHILIPPlllES, UNIER THE AUSPICES OF THE WE:3TERN PACIFIC REGION OF WHO FROM 16 - 29 OCTOBER 1957

*WPRO/SOC.PREV.MED./A-l *WPRO/SOC.PREV.MED./A-j

SCHEDULE OF ARRIVALS

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ITINERARIES OF PARTICIPANTS AND WHO STAFF

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REPORTS OF GROUPS I, II and III on agenda item 2 REPORTS OF GROUPS I and II on agenda items 3, 4, 5 and 7 REPORT OF GROOP II on item 8

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E&F Minutes of the Plenary Session on Agenda 2

WP.RO!SOC.PREV.MED./Min!l WP.RO/SOC.PREV.MED./Min/2

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Minutes of the Plenary Session on Agenda 3

*Not distributed to the participants.

WPRO/SOC.PREV.MED./Min/3

.. Available in Document Number WFRO/SOC.P.REV.MED./Min/3 WPRO/SOC.P.REV.MED./Min/4 WFRO/SOC.P.REV.MED./Min/5 WPRO/SOC.P.REV.MED;/Min/6 WPRO/SOC.~1.MED./Min/7

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J. T1.tle Minutes ot: the Plenary Session on Agenda 4 Minutes of the Plenary Session on Agenda 6 Minutes of the Plenary Session on Agenda 5 Minutes of the Plenary Session on Agenda 7 Minutes of the Final Plenary Session English (E) and in French !Fl Eo~

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WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16-29 October 1957 TENTATIVE AGENIlA 1.

REX} IONAL

OFFICE FOR THE WESTERN PACIFIC

WPRO/SOC.PREV.MED./l-Rev.l 12 October 1957 ORIGINAL: ENGLISH

Opening session Introductory discussion on the teaching of social and preventive medicine medicine

3. Curriculum content and methodology of teaching social and preventive

Organization of Department of Social and Preventive Medicine and other departments of a medical school

5. Relations between the Department of Social and Preventive Medicine 6. Role of the Department of Social and Preventive Medicine in comprehensive health care 7. Practice facilities and community research of the Department of Social and Preventive Medicine

8. Final session (summary of discussions) 9. Future planning General evaluation Closing session

NOTE:

Visits to the following institutions are proposed during the discussion period: - Institute of Hygiene, University of the Philippines - Department of Health - Medical schools in Manila - Other training facilities and agencies of social and preventive medicine

WPRojsOC.PREV.MED./I-Rev.l Fage2 SUGGESTED ITEMS OF TOPICS OF THE AGENDA. 2. Introductory discussion on the teaching of social and preventive medicine 2.1 2.2 2.3 What are the objectives of the undergraduate medical education? ~are

the objectives of the teaching of social and preventive medicine? -."

What is the role of the physician in the community?

Curriculum content and methodology of teaching social and preventive medicine 3.1 3.2 3.3 What should the curriculum of social and preventive medicine include? What should be the duration of the courses? What teaching methods should be used? Theoretical instruction and audio visual media, seminars, laboratory, field visit, field work, etc.? How clinical approach in teaching social and preventive medicine can be incorporated. What is the contribution to the teaching of social and preventive medicine which might be made by other departments of a medical school? What is the contribution to the teaching of social and preventive medicine in pre-professional education? What participation should be assigned to the student in the local medical care and welfare services, within the programme of instruction? What is the most appropriate time to assign the student to activities of public-health services? Is it advisable to include a period of "internship" in the publichealth services as part of the teaching of social and preventive medicine?

3.4 3.5

3.6 3.7

3.8 3.9

Organization of Department of Social and Preventive Medicine 4.1 4.2 What are the functions of the Department of Social and Preventive Medicine? Is a separate or independent department necessary? How should the teaching of social and preventive medicine be organized? (Integrated and continuous teaching as opposed to separate and independent instruction?)

4.3

4.4 What medical •••

•

WPRO/SOC.PREV.MED./l-Rev.l Page 3

4.4

What medical and other personnel are required to carry out suchteaching? Who of the members of the faculty should work on full-time basis and who on part-time basis?

4.6

How should the teaching personnel of the Department of Social and Preventive Medicine be trained? Medicine and

5. 5.1 5.2

What types of relations exist at present and how do they influence the process of training the physician? What type of co-ordination is required to attain the objectives in teaching set out to be accomplished? a. Teaching relat:i.Qns, integration of courses and joint seminars on topics of common interest, combined appointments of personnel. Exchange of services with other departments, clinical and laboratory consultation, advisory services on statistics, epidemiology and administration. Joint study of clinical problems or other problems of community or group interest.

5.3

How can the integration of the principles and techniques of social and preventive medicine and medical care be achieved during the development of the teaching programme? What responsibility is assigned to the preventive medicine department in the integrated teaching programme?

5.4 6.

Role of the Department of Social and Preventive Medicine in cOmprehensive health care 6.1 6.2 What is the concept of comprehensive health care? What is the responsibility of the medical school in teaching comprehensive health care with spe~i~l reference to that of the Department of Social and Preventive Medicine? What are the methods of teaching comprehensive health care?

6.3 7.

Practice facilities and community research of the Department of Social and Preventive Medicine 7.1 Should the community and its services be used in medical education? 7.2 How can •••

•

WPRO/SOC.PREV.MED./l-Rev.l Page 4 7.2 How can the resources of a community be utilized as a teaching laboratory to train the Physician? Whatstandards should be set up for both service and training in these practice facilities? How can the Social and Preventive Medicine Department and the medical school as a whole contribute toward improving the local health services and the practice of social and preventive medicine? What functions are incumbent on the health services in the activities of the Department of Social and Preventive Medicine? What are the fields of research appropriate to the Department of Social and Preventive ,Medicine? What are the contributions of the Department of Social and Preventive Medicine to other departments and agencies, and collaborative studies with the latter?

7.3

7.4 7.5 7.6

WORLD HEl~LTH ORGANIZ.ATION STUDY GROUP ON SOCIAL .MID ffiEVENTlVE MEDIDINE Manila, Philippines 16~29 October 1957

REGIONAL OFFICE FOR THE WES1ERN PACIFIC WPRO/Soc.PREV.MED./2 23 August 1957 . ORIGlNi.L: ENGLISH

RELll.TIONS BETWEEN 'IHE DEP1.RWENT OF SOCIAL .. NO PREVENTIVE MEDICINE MID OTHER DEPI>R'lMENTS OF TIE MEDICIJ, SCHOOL by

Hilario Lara"

M.D., M.P.H., Dr. P.H.*

CONTENffi

~ ;L 2

INTRODUCTION MEDIC;u. EDUCATION 1~ GROVll:NG pmCESS TO MEET CHl>NGING NEEDS OF SOCIETY CDIUB OF MEDIC.\L EDUOl. TION AS GUIDE SHt .. PING ATTITUDES MARSHtioLLING RESOURCES 'IO SEEK BETTER WAYS

4 7 8

4 5 6

CONCLUDING STan!MENT References Diagramatic Sketch of the Origin and Growth of Present a1 d Future Departrrents of the Institut,e of Hygiene

1.3

Annex I Annex II

Annex III Questionnaire

*Professor and Head of the Department of Hygiere and Preventive Medicine, College of Medicine; Professor and Head of the Departll2nt of Epidemiology am Public Health ..dministr'ltion; Dean of the Institute of Hygiene, University of the Philippires.

•

WPRO/SOC.PREV.MED./2 Page 1 1. INTRODUCTION

The relations between the Department of Social ani Preventive Medicine am other departments of the medical school for the teaching:;f this important discipline to medical students are subject to the influence of maQY factors. However in obtaining tho most desirable type of interdepartmental relationships for purposes of co-ordination and/or integration of instruction in the greater interest of sound medical education, the joint effects of the several factors listed below, which should largely de~ermine the extent and quality of such relationships, should not be lost sight of1 namely:

(1) The rGalizati:;n by all concerned that medical education, including the teaching of social and preventive ne dicine as a discipline, is a complex process which is susceptible to various changes in line with the advance of science and the changing needs of society. (2) Full understanding and common realization among the various departlEnte md the entire faculw of the medical school of: (a) the over-all goals of medical education and (b) their individual and group responsibilities to achieve ths said goals. The kind of leadership and staffing of the various departments of the medical school. the school and his department heads may pursue - whether favora~ or adversely inclined towards better co-ordination and/or integr::tion 0 f teaching.

(3)

(4) The type of medical school administration that the Dean of

(5) The attitude toward preventive and social medicine as a disciplino manifested by higher echelon policy-making and administrative bodies or officials of the University with which the medical school is affiliated, connected1 and/or a componen-t part of. (6)

The att~tude toward, co-operation, and supjJort of the medical end public-health professions to quality methods of medical education and their encouragement of a high standard of performance by their medical school which can onl3" arise from the establishment ot: nrutual understanding and co-operative relationship_ Miscellaneous and/or extraneous influences that can help promote the healthy functbning !lld development of all the departments of studies and units of the medical school as well as various similar forces (national, regional, and international agencies, foundations, etc.).

(8)

The standing a m prestige enjoyed by the medical s choall s D6partment of Social and Preventive Medicine itself and the extent :;f recognition by the entire medical faculty of the importance of this discipline in the whole scheme of modern medical education to lEet the needs of modern sociew_ (9) The realization •••

WPRO/soc .PREV.MED./2 Page 2

(9)

'Ihe realization by the Department of Social and Preventive Medicine of the fundamental role of these factors taken together - (1), (2), (3), (4), (5), (6), (7) and (8) - in the interest of modern quality medical education, and The realizati~n,among other things, qy the Department of Social am Preventive Medicine of the essentiality of various motivations and its ability to make use of the same for securing the active support and co-operation of all elements - more especially of all the departments and units of the medical school - in the furtherance of the cause of this discipline. 2. MEDICAL EDUCATION:" GROWING PROCESS TO }-mET CHANGING NEEDS OF SOCIETY

(lO)

One of the basic ingredients in bringing about a healthy state of relationship between all the departments of the medical school in the teaching of social and preventive medicine, or any other disCipline for that matter" would be a deep realizatio n on the part 0 f all concerned: (a) that medical education in general is a complex process and that the teaching 0 f s oeial and preventive medicine as a discipline is part and parcel of that process; tha t it is not static; that it is a growing and purposeful process in which maIG'" and varied circumstances are involved in a system of greatly controllable interactions between: (i) (ii) the required SEEDS of scientific facts, principles, philosophy and practices; the adequate teaching facilities of the school, the SOWER, for the proper acquisition and transmission of the requisite seeds; and the proIB rly selected studen t body, the SOn.;

(b) (c)

(iii) (d)

that the growth and development of that process must take place pari pasu with the advance of knowledge and hence of civilization itself; that while one of the other hand contribute and the improved condition of medical education is effects of the advance of civilization, on the improvc-d medical education has much also to in its own way to the advance of civilization;

(e)

(f)

that nedical edUCation in general.and the teaching of social and preventive medicine in varying degrees of co-ordinated and/or integrated relationships with those

of the

...

WPRO/SOC.PREV.!-IED./2 Page 3 of the other disciplines, in particular, woulQ never reach an ideal state of perfectbn. .Dearing.:Y has most appropriately expressed the point: "This means that no standard pattGrn for medical education can be applicable in all times and places. 1'lha t society requires 0 f a msdical school in Edinburgh or Boston will not necessari~ moet the needs of society in lliailand cr Lambarene. Yet the faculties, students, and practitioners in all these widely differ:,..ng societies have much to share in knowledge and expcriGnce," There is therefore a serious need for continuous, extensive, and systematic co-operative examination and study of the various phases of the problem of medical education, more ospocially as regards the teaching of social and preventive medicine in relation to the teaching of other disciplires, - on the institutional, nc.tioml, regbnal and international levels - before any concrete proposal can be advunced for adoption of some desirable ndninnun standards particularly applicable to certain sets of conditions, tO~1rds which the progress of the medical -education process could be properl,y directed to afford the degree of satistactor,y service the peoples living under such conditio~ might need. '!he" rapidly changing d.imensi:Jlls of mediclll. sciencell.Y would demand such a course of action. Our mid-ioth century system of medical education is the outcome of system tic efforts at improvement produced through the application of the nathod of trial and error. In the words of Professor Rene Sand:lI "the histor,y of medical education :iB dominated by improvements in pedagogy, which enrich its methods; by progress in science and technology, which widens its scope; and by the needs of society, which dictate its curriculum." x x x Medical schools to-day should give dUEl regard to the fact that the advance of Civilization does give ris" t:> many inherent problems in the amelioration or eradication of which they (the schools) must help socie1:iY secure adequate means of solution. No m~dern medical school which ignores this responsibility can be said to be fulfilling its mission. Society knows this. ':"nd society 'Will help its medical schools Oll~ to the extent mediclll. schools actively and effectively help ne et the needs of society. On this point one past president ofth.e;i.soociation of AlOOrican M~cU.cal Colleges said in connectio n with university medical education :!Y "FacultiGs of medicine must accept certain fundarnental oblications which are essential, if they wish to rGmain an intoGral parts of universities. These oblieations are: to comIrehend the truths upon which modern medicine has grown to its presont stature; to on:L.,rge this body of truth by research which is always most critical~ monitored; to pass those truths on to our students alOOf with tho requisite technical

i4PRO/SOC .PREV.MED.!2 Page 4 requisi te technicf:.1 skill nc:cessary to employ them in thu practice of rodicuw; to do all in 'Our power by attitude and positive action tJ forward the students' cultural interests throughout the period of undergraduate st~ and hospital tr['.iningj to romember al> ays that we are educ/,\ting a phySician, whose life "lill be EJlBnt in the care of the sick, a task which requires that he develop a disciplined imagination; we are not training a bedside dialectitian who, becauso he has not acquired knowledge imaginatively, will confuse the transient "scientific fact" with truth." x x x

OOALS OF MEDICl.L EDUCl. TION

:.s

GUIDE

'lblCoIJrado Springs CJnference2! held in November 1952, which was cosponsored by the Conference of Professors of Preventive Medicine and the Association of "meric['.n Medic21 Colleges in which 76 medical schools in the United states and Canada wore represented, advanced this very fundamental belief: • • • "that all phYSicians, in additbn to requisite knowledge and ability to diagnose and treat disease, should have the broad goals of h.:k"llth always in mind; they should have a spirit of scientific inquiry, a broad understanding of the natural history of disease, a knowledge of PC;)p1e as 'Hell [(s disease to the environm(;nt, and the ability to call into ;Jlay whatever. services may be necessary to secure comprohensive health care." x x x No system of co-ordination and/or integratLln of educatbnal efforts will be healthily fruitful unless there is full understanding and common realization among the various departments'and the entire faculty of the medical school of the over-all goals of medical education and of their individual and group responsibilities for the att['.inment of such goalo. The problems incident to an effective teaching of soci['.l and preventive medicine to medical stUdents are complex and inv~lve many facilities. This fact would seem Dll the m:;,re to indicate the ned f:)r til" soundest working rclatbnship between 1'111 the departments ani units :)f the nedical school and ~thers concerned~ in order to atbin to the fullest extent possible the desired coals tomrd which medical fcculties the world over are exerting their unremitting efforts. 'Jhe more det8.ilod objectivos of undergraduate medical cducgtbn been formulated trr the .,ssociatian of •..rrLrican Medical College£! as follows: .iU

h~.ve

To help

too

student acquir" requisite knowlodge: ~f

Of the normal development, structure and function hunnn being.

the

Of the common disorders of development, structure or function. 3. Of tho

WPRO/SOC.PREV.MED./2 Page 5 3. Of the manner in which physical, chendcal and biological agents as well as heredit ry factors, psycholor;ical factors, livinc habits and s:>cial forces effect the human bei~ faVO!r""'h1y or unfnvourably. Of the availability of a wide variety of diagnostic, operative and other therapeutic procedures in the hands of specialists. Of the f'eneral techniques nod resources available both to the individual and to the community for the preverition of disease and the maintenance of health. Of the social nod cultural aettings in which medical education and practice are carried on.

5. 6.

To help the student establish essential habits:

Of continuingsolf-education, through critical reading and evaluation of information, and throuE,h the usc of the scientific ne't.hod in approa ching medical problems. Of thoroughness and accuraqy in carrying out diagnostic and therapeutic pncedures. and perceptiveness in the handling of

3. Of consideration patients.

To help tho student achieve basic skills:

1. 2.

In eliciting an accurate and adequate history. In making physical oxandnnti:Jn and utilizing effectively such instrumonts ~s are corunonly used by all physicians. In performing and interpreting essential laboratory tests and in requesting and interpreting special studies conducted by technicians or by speciril ists.

It.

In usi~ assembled data to provide a val id diagnostic appraisal and an effective course of action, calling upon addition~l specialists' services and community services as needed. In interpreting findings arxl diagnosis to p?,tients in such a way as to givo hope and understanding and to avoid undue apprehension and pessimism. fandlies.

6. In winning and hoJ.rling the confidence of patients and their

7. In working in the medical team of phySicians, nurses, social workers, physical therapists and others.

In working in the community team of official end voluntary institutions ~nd agencies providing health services.

D. To help

...

WPRQ/SOC.PREV.MED./2 Page 6 D. To help the student develop sound attitudes:

1. 2.

Of viewing individuals in their entirety as conplex human beings in a complex and changing envir:mment. Of seeking ways to promote and to maintain patients' health, understanding tha t it :is more effecti. ve to prevent disease than to cure it. development, structure or function, the cause and cure of which are problems to be solved by reans of careful scientific investigation.

3. Of approaching each ill patient as a person with disordered

Of basing the plan for cure, rehabilitation or adjustment to permanent handicap upon the joint efforts of the medical team 000 patient to ass:ist nature's healing powers. Of exp3 dang to be a student all his life ani to Ja arn and to revise old thinking as long as he continues to practise medicine. relieve often, prevent frequently, comfor t always.

6. Of accepting the fact that the physician can cure sometiml s, E. To help the student gain an understanding of professional and ethical principles:

Of being willing to accept the responsibility for the initiation and continuing co-ordination of all of the efforts directed toward the patient. s problem or problellE as they relate to his health. Of establishing definite diagposis and treatmant only after adequate stuqy. Of supplementing one' s own judgment, as occasio.tll"equires, with the u sdom and couns el of competent medical specialists. Of charging fees in proportion to the tine, skill and special facilities required aoo with due regard for the patient's economic circumstances. Of being mindful of his obligations to the colllDU.lllity as a phySician, with reference to the cOlll1lunity's problems of health, ani disease, and equaJ.l,y as a citizen. reputation of one' s colleagues. .'

4. 5.

6. Of respecting the rights and dignity of patients ani the 7. Of extending freely his profeSSional aid in aqy erne..

The objectives of undergraduate medical education DO NOT include: 1. J.. t ten¢ing to •••

~ency.

WPRO/SOC • .?REVoHED./Z Page 7 1. ;.ttempting to provide the detailed systematic knowledge of anatonw, biochomistry, physioloEY, micro biolof-Y, p dhology or iJharmacology required of craduate students me'Joring in one of these fio1ds.

~ttempting to provide a detailed presentation of

all the

disorders that affect tho human being.

atte~)ting

to )rovide a detailed presontation of all the phySical, chemical, and biological agents, hereditar,r factors, psycholo[ical factors, living habits and social forces that may affect tho human being favorab4r or unfavorably.

~ttempting to teach tho techniques required for the suc-

cessful practice of the various specialties." The above listed objectivos Should serve to regUlate to a nnrked degree the extent of the teaching of social nnd preventive medicine to medical stUdents in rel'1.tion to the teaching of other disciplines.

SHAPING ATTITUDES

Aside from complete understanding on the part of all the departments and the entire faculty of the me.dica1 school 0 f the above stated objectives, and the full realization by all coreerncd of their indivdual and group respo rnibilitios for the attainment of the COllJllon goals, which, amng o thor desirt!ble things, all quality leadership and staffing of the various dopartments am units of the school would syskmatically strive for, the d3partment of preventive and social medicino would do well to mind the serious task of p~moting the kind of interust, attention nod/or attitude from the medical schJol ~uthori ties in order that tho administration would activeJ..y bring intJ focus th" teaching of this discipline in relation to the teachings of all other departments of the school. The attitude of hirhBr echelon policy-making bodius and officials of the University with which the medical school is affi1itated, connect8d or a part of, am the attitude tJward and support of the community to a desirable proGre.IllIOO of ~ality tec.ching of social and preventive medicine, and for that matter of nny discipline Df study, will depend J;>.rgely on the kind of lcc.dorship employed b,y the department concerned. The most desirable mode of actiJn in this regard which will likely aain the support of all parties concerned, would bo that which takes into cJnsiderativn all factors involvod - pedagogical, financial, orrmizat1onal, ethical, etc. The teaching facilities of any department of study can only grow so much in r"lation to tho other departmonts of the modica1 school. Unless the department concerned possesses some degree of onterprise, and will accept added responsibilities beyJnd its normal share of work in relation to those of the other d£partmentf} arv attenpt to expand its . facilitios is bound to meet oppositiJn. Howover, if tile other component units of the medical school and others concerned roalize that the programme of development and expansion of the services Jf tho department will not •••

WFRO/SOC.PREV.MED./2 Page 8 will not affect adversely, but would rather in many ways 0 ffer advantages favourable to their indiv:idual ar.rl group interests, and mre especially nati:mal interests, they will gladly give to the said programme their full co-operati::ln and support. The degree of appreciation and support of the programme af teaching and research in social and proventive medicine will grow strongly in proportio n to the realization on the IE rt of all concerned of the I%' ogramne f s true worth and over-all benefits that the communi~ will derive from it. Such realization will result the more readily and chiefly from a cognizance of the more diBcernible values am bomfits rather than the many intangible ones which only the experts could vory W3ll see. The non-recognizable benefi ts must be made recognizably and convincingly cleqr by all practicable and agreGable lreans possible i f we would oxp; ct general appreciation nnd acceptance of this diBcipline, so that as much as possible its principles, practices, ar.rl philosophy would be embodied into the teachings of the other departments. Such "fforts might then result, runong other things, in the teaching of ths preventive and soc ial aspGcts ·'Jf health a r.rl disease not beirg the sole responsibility of the departrent of social and preventive medicine but rather the joint resp:msibility of all the departmlnts 'Jf the nedical school. weekly faculty clinical conferences, the \2ekly (student-faculty) clinico-pathological c:mferenc6s, the I'Ggular nnd SpEcial meetinGS of department heads, the faculty seminars and work-shops, faculty committee and board meetings, symposia, am other similar lIl£etings .lill provide additional opportunities for estnblishinr varied degrees Jf contact and understanding in the interest of whatever co-ordination and integration possible in the teaching of the social, promotivG, ;JI'e'ICntive, curative, nnd rehabilitative aspects of mdicine.

The

, . j I

Hi.RSlliILLING RFSOUff:ES 'IO SEEK BETTER ltiYS

Brevity requirements would not permit full treatment of all tho points raised in the foregoinr discussions. Nonetheless the experience of the Departmcn t 0 f Hygiene and preven~1e Medici no of the Colle ge of Medicine of the University ~f the Philippines-!! in its attempt to obtain more facilitiGs for the teaching of this important discij;)line, might here be cited to illustrate one or two points considorod in tho discussion. OUl'9I)e p artlOOnt of HyEiene lid Prevontive !oicdicine (now the Institute of Hygiena)Z/- jointly with Jur Bureaus of Health and Public l.Jelfare, with sone fimncial assistance from the Rockefeller Foundation E.stablished two units of service, one under a rural setting (Binanconan, Rizal) add anothor under an urban setting (Paco, Manila) for tho purpose, am~'ng Jther things, of provid~g addi~i~nal fnci~tks for improvin£ ::lUI' teachinf71f preventive md soc~al medic~ne to med~cal am pUblic-health students.In addition short~ before World W~r II, this dcpartmnt also mJnitor~d the establish~ ment,of'a he~lth clinic in the Dispensary Building 'Jf tho Philippine General Ho~p~tal, .-1 wh~ch was o!JGrated 1?lld st~dfed jointJ,y by this departmnt and the clinJ.cal,u~partments of our ColkLe of MediCine, so as to provide more o~po-:tu~l1tJ.es for better co-ordination ani integration of teaching of this dJ.scJ.plJ.ne to medical stooents with emphasiB on child health and nutrition Unfort;unate~ World 1';ar II destroyed all these facilities. In 1950 with • some assistance ••. "";;.

WPRO/SOC.PREV.MED./2 Page 9 some assiBtance from iiiO and UNICEF the Head 0 f the Department of Hygiene am Preventive Medicine established for the sane puxpose as those units in 1929, the Rural Health DelIDnstrati:-n and Trainin[ Center a t Quezon Oi ty. 'lhese units also served to p rov:ide more conveni~t facilities for demmstrating the application of certain principles and methods learned in the classrooms under actual conditions in the field. The present state of ITlIltual un:ierstand1ng and co-operation obtaining among the different departnents of the College 0 f Medicine , University of the Philippines, in the teaching of social and preventive medicine to medical students" and the extent 0 f expansion of the services of its Departrent of Hygiene am Preventive Medicine (see also :.n.~c::.;;s II n.nd III) w'ill S UPP;lL'"i:., although only in a limited sense, the lX'acticability of the ideas expressed in the foregoing discussions. Ihe procedure we have followed in attaining our objective should not, however, be interpreted in arv way as an ideal method suggested for other schools to pattern after their method of approach to their problem. At any rate our efforts at experimentation to obtain some degree of improvement in the tel.\Ching of social am preventive medicine to our students have be.en to us quite stimulating and to a degree encouraging. The Dean, jointly with the Professor an:!. Head of the Departrent of HYgiene am Preventive Medicine, distributed on 13 May 1957 a set of questionnaires (see ... Q DoX IU) among the eleven department heads of our College (Hygiene and ~reventive Medicine excluded). The results of this inquiry are herebelow Ir esentedc

%Devoted ~

Number of Departments 0 1

1 2

• .

6 - 9 10 - 15 16 - 19 20 - ~4 25

3 1

1 . To the •••

wpoo/soo .PREV.MED./2 Page 10

Teaching Frequency All the time Often Ocoasionally Rare4r Not at all

Number of Departments Answering 2

I..verage % Devoted

12.5 15.0

5 1

Categories (a) Solely the Department of Hygieoo (b) Mainly the Department of Hygiene (c) All the Departments of the College as >211

Number 0 f Departments Answering 1

•

5 8

Cd) Chiefly IllY department in IllY subject And to the question - "Whose res ou consider the te aching 0 f Socia 1 Hed"!'l'::'cl::=n-:e-a:-::::r'7::::-"";;:":;:"l:7-::"""n~""'tr-h~t~o';;';;';o;:;ur;;':;';;:;m;";;e~l;;;;c~:al.

stUdents to be?" - the answers medical school are distributed Categories (a) The sole responsibility of the Dept. of Hygiene (b) Main responsibility of the Dept. of Hygiene (c) To some extent also the responsibility of 0 ther departments of our college

departnents of our Number of De}:e.rtmen ts Answering 1

8 The ratio .•.

WPRO/SOC.PREVJKED./2 Page 11 '!he ratio of the required hours of our uniergraduate medical student's programme of work in hygiene and preventive medicine subjects to the total hours for the study of all other disCiplines in our medical school curriculum by year of the students' progranune of schooling may be noted in the following table. (See also the Official Ga talogue of the University of the Philippines.) Ratio of Re uired Hours and Preventive Medicine Sub'ects to Total Hours ubjects in Hedica Year Total Hours for Hygiene fo r Medical Year %of Total for Med. Year

Hours for Hygiene Subj ect ~L~ec~t~u~r~e~'------------------To--t-a-l--H-o-ur--s

Total Hours for Ked. Yr.

Medical Year

HygieneProper Med. Subject

Conference and Demonstration

Laboratory

Field lvork

% of Wo •• Med.

No.

Yr.

1. First 2. Second

1152

1136 Hygiene l-M (Medical· Microbiology) Hygiene 20M (Parasitology)

288

176 15.49

ll2

3. Third Hygiene 3-M (Hygiene and Public Health) .!Ie

112

9.72

1152

112

Fourth Hygiene 4~

(Public Health Pro-

blems) TOTAL

-32

lOOn

132 11.46 532 11.58

1152 4592

132 532

11.46 11.58

288

100

n - Estimate of hours devoted to required field study done during swnmer vacation

to prepare required sanitary survey of conmunity where student expects to practice medicine after graduation. The problem •••

WPRo/soc .PREJ .1'1ID./2 Page 12 The problem of co-ordination in the teachi~!i of tw:> pre-clinical basic disciplines, ~ical microbiology (hygiene l-M)-." and medical parasitology (hygiene 2~)~ has been dealt with by integration through transfer of these two disciplines together with the staff an~ transferable teaching equipment to the Department of Hygiene and Preventive Medicine. The graatJ,y expanded status of our department which has metamorphosed into an Institute of Hygiene (see :. n no x II. also Catalogue and Announcements of too University of the Philippines), doing research and extension w:>rk and offering both undergraduate and graduate courses in hygiene, preventive medicine, and public health, has been brought about by the joint effects of the several factors mentioned above. The relationship established in the Department "With the Office of the Dean and the various departnentsof our !",l:dical school has had, however, the benefit of some advantages which perhaps other schools might not have been favored with. F1rstJ,y, the greatest majority of our most-experienced faculty members including the department heads arxi all the younger members of our teaching staff had been former students of both the present Dean and the Head of the Departnent of Hygiene ani Preventive Medici.re and the refore exposed to their points 0 f view on the preventive and social aspects of medicine. Secondly, both school officials (the D:lan and the Department Head), thanks to the fellowship system of the Rockefeller Foundation, had had some exposure to the idea arxi practice of permeating the clinical teachings li. th the social and preventive aspects of medicine which are in vogue in a number of western medical schools. ThirdJ,y, both had attended the same school together, and had been profeSSionally associated with each other for the last 32 years. Fourthly, our institution, in addition to the financial support of our government, had also been fa vorad with several fellowships and other form of teaching grants from the Rockefeller Foundation, the United States Public Health Service, the Kellog Foundation, the World Health Organization, the China Medical Board of New York, and the United States International Co-ope ration Administration (lCA) which in the interest of medical and public-health education and research might in reiteration be acknowledged hera with deep appreciation. By no means is it claimed that the relations obtaining between the Department of Social and Preventive Medicine and other departments of our medical college are perfect or wholly satisfactory. Thera could be nothing further from the truth. Our Department of Hygiene and Preventive }1edicine, with the support of the Dcan, has laboured hard to secure some degree of acceptable (to us) relationship with the other departnents of our college in the teaching of preventive and sx ial medicine. But until more precise criteria for quantitative appraisal of the most desirable kind of interdepartmental relationship in the teaching oI this discipline to medical students have been established, it is felt that any views or opinions on the status of such relationship obtainill!: in our medical school, and for that IlB ttar arv medical school, will remain qual itatively subjective and, to say the least, generally incomplete i f not grossly inaccurante. lie have been merely, arxi are still engated, in an experiment, as other medical schools also are, in the field of medical education under a setting we believed adapted to our own special conditions with a view to obtaining some kind of improvement in our teaching of the subject. For the last thirty-two years we have strived hard to introduce changes as circumstances have allowed us in our teaching of preventive and social medicine in rela tion to the teaching a f other disciplines, realizing that no progress

'J,

in this ...

WPRo/soc. PRE v.1 ED ./2 Page 13 . in this phase of medical education would be possible without change. Nevertheless in our earnest endeavour at improvement we.have also occupied ourselves with making "haste slowlyll recognizing the truth in the saying"that not all change is progress." Errors in our views there could be. But we wo uld take heart in De Morgan's sta tezoont:

\ t

"Wrong hypotheses rightly worked from have produced more useful result than unguided observation. 1I

conCLUDING STA'lm4ENl'

.......

The view is here advanced that full understanding and application of the idea of "·oint-effect of com anent factors ll , which have been considered severally but brief y in this report, is as~c to progress in attaining a desirable degree of inter-departzoontal relations in the teaching 0 f social and preventive medicine to medical students. '!he method of approach to the problem of inteI'"departmental relations in this regard would vary from school to school in point of "times", "places" and -resources".

WPRO/Soc.PREV.MED./2 ANNEX I

REFERENCES

DEARING, W.P. New orienta lion in the teaching 0 f preventive medicine. Hlth Rep. (Wash.), 68, 1147-1155, 1953

Public

BARRY WOOD, Jr., W. The underlyine cause of unrest in university medicine. med. ASs., 533-552, 1957 SAND, Rene

J. Amer.

3 '-

General report 0 n technical discussions on the education and training of medical and public health personnel. ehron. Wld Hlth Org., 287-303, 1951

4 5

DaRTS, S.E. The medical schoo 1 within the Educ., ~, 11-20, 1954 II

Idea of a Uni versi ty" •

J. lIIed.

CU..RK, K.G. (with editor:ial committeea Hubbard, J.P., Chairman; Berry, G.P., Dingle, J.R., Florio, Ll. and Tussel, d.E.) Preventive medicine in medical schools. rleport of Colorado Springs Conference, November 1952

EXECUTIVE COUNCIL OF THE ASSOCI1l.TION OF LHE3IC1.N MEDIC1IL COLLEGES. The objectives of undelgraduate medical education, eighth revision, 1953. J. mad. Educ., ~, 57-59, 1953.

PHILIPPINES Catalogue and i.nnouncements - School of Hygiene and Public Health, University of the Philippines. pp. 12-13, 1931-1932 PHILIPPINES General catalogue - University of the Philippines. 1956-1957 and Announcements, pp. 473-509, 1957-1958 (See Department of Parasitology) PHILIPPINES Catalogue - Institute of Hygiene 1957-1958 and AnnouQcemants 1958-1959 (See Department of Medical Microbiology)

DIAGRAMATIC seETCH OF THE ORIGIN AND GROWTH OF PRESENT AND :FUTURE DEPARTMENTS OF THE INSTITUTE OF HYGIENE

ANNEX II

( 1925 ) DEl' ARTMENT OF HYGIENE AND PREVENTIVE MEDICINE I ________________ _L

(1927) DIVISION OF HYGIENE AND PUBLIC HEAL ,

Sea. of Biological EYgien

-->

( 1 9 29) DEPT. OF SAN. BACTERIOLOGY AND IMIlUl10LOGY

Sec. of Chemical Hygiene Sea. of San. Engineering Sec. of Biostatistics

DEPT. OF SAN. ENG.INIXJSTRIAL PHYSIOLOGY AND CHEMISTRY

(1953) DEPT OF CHEMICAL HYGIENE -"""","I .AND NUTRITION

,, , /

H Y

Chemical Hygiene Sanitary Engineering

j- --

f- - ~

Sec.of Epidemiology Seo. of Public Health Adminietration

--~ DEPT. OF EPIDEM. ,BIOSTAT AND ;" PUB. HEALTH ADMINISTRATION /

(1929)

Div.of Biostatistics

H I \

Div. of EpidemiOlOgy~ , ,

YDiV. -of Public Health ~// Administration

Ji'====== ======'jI II -- --"

LEGEND: Operating departments of Institute 1956-1957 OPERATING EXPENSES: ~12,OOO

fF== = Administration

i!:=== _(~~~s....)====,!j = (PoorosEiif ====11 ADI!

(PROPOSED) DEPARTMENT OF EPIDEMIOLOGY

- ---:iDEPARTMEliT OF PUBLIC HEALTH

~ = = !:1t~~TIJ!.T1"~ (J'ld1lJ = =r,L r . - - - - - - - - - - -, I 'I'1..Div. __ of_ I' .Hea.l _ _ tb. __ Practice _ _ .......~ I h Div. of _ Health Educa.tion 1 __ ___ _ _ _ ....JriI

r----------, ~

1926-1921 =

(Department of Hygiene and Preventive Medicine of the College of Medicine 1930-1931 D '72,000 (School) - Concurrently Department of Hygiene College of Medicine 1956-1957 = ~269,235 (Institute) _ Concurrently Department of Hygiene College-of Medicine.

H ru: v~ of 1

P. _ Heal th_ _ ..1 ~ L ____ __

Ad;

1 --_-_-----,1 ~iV:-of Child& Vaternal!J ~

~iV.Of Hosp.Administratio~ L _________ -' I

~e~lth

___

---J J

~.JDi v. ~fM;di~al-E;;n~i~

1,---------"

L- _and .!.edic~.L~a.£.e_ ---1 1

L402V.of Oocupational Healt~ 1- _________ ..1

·, WPROjSOC. PRE\! • MEn .j 2

ANNEX HI INS'ITW'fE OF HYGIENE University of the Philippires Manila

May 13, 1957 'ilie Head Department :Jf College of Medicine, U. Manila Sir: We are interested on the extent the preventive and social aspects of disease are covered in tre teaching activities of the various departments of the College of Medicine of the University of the Philippines. It will be [,reatly appreciated if you would, to the best of your knowledge, kindly check the answers to the questions here below enumerated and return th: completed form at your earliest convenience.

:T"'...,....-.............. ~---- P.

PLEASE CHECK ANSIER

... 2.

What per cent of your teaching do you devote to the consideration of matters bearing on some aspects of the prevention of disease? (Check only one) (0%); (1~ or less); (2%); (3%); (4%), (5%); (6%); (10-15%); (16-19%); (20-24%); or what? If more or less than art:! one amount mentioned above, state approximate percentage _ _ _ _ • lli you ever touch on the social ~licatiOM of disease in your

teaching of your subject? (all the time); (often); (occasionally); (rarely); or (not at all). If you do, what per cent of your teaching do you devote to it?

Do you consider tIE teaching of preventive medicine to medical

students to be the responsibility of: a. Solely the Department of Hygiene? (Yes) (No) (Not certain) b. Mainly the Departmant of Hygiene? (Yes) (No) (Not certain) c. illl the Departments of the College as well? (Yes) (No) (Not certain) d. <l:tiefly nw department in nw subject? (Yes) (No) (Not certain)

•

Do you cons ider th€ teaching 0 f Social Medicine and or Public Health to our medical stUdents to be: The sole responsibility of the Department of HYgiene? (Yes) (No) (Not certain) b. Main responsibility of tIE Departmant of Hygi6ne? (Yes) (No) (Not certain) c. To some extent also a responsibility of other departments of the College? (Yes) (No) (Not certain) 18 T INDOHSEMENT •••

.' , WffiO/SOO.ffiEV.MED./2

l,nnex III

Page 2

1ST INDORSEMENT Ii

Comformably returned to the Head, Department of Hygiene, College of Hedicine, University of the Philippines. hnswers to questions furnished by:

Dr.

Rank~:"""("'Pr-o-f""e-s-s-o-r"T)-;'T"V.,-l.S-S-o-c-.-....PI=,--of.,,..... );-,(,..,A,-s-s.... t-.-P ...r-o~f,....-r)

(Instructor); (••sst. Instructor) Depart/ll3nt of _______________

;.«):tLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC "I'lPRO/SOC.PREV.MED./3

iillD

STUPY GROUP ON SOCIAL PREVENTIVE MElSIbtNE

20 August 1957 ORIGINAL: ENGLISH

Manila, Philippines 16~29 October 1957

THE TEiLCHING OF PREVENTIVE M;n SOCIlJ:. MEDICINE. THE CURRIC ULUl1 by

Edward Ford, M.D.*

-1 2

CON'lENTS Page TII'IRODUC TION

1 1 2

GENERi.L CONSIDEIl..:" TrONS THE PIDBLliH OF CURRICULUM lMPROVI!}tENT THE CONTENT OF '1HE CURiUCULUl-1

4 5 6

'!HE CLTIlIClu. APPRO.'\CH THE CONTRIBUTION OF OTnER DEPllR'lMENTS TO THE TEACHING OF PREVENTIVE IJW SOCIllI.

...

MEDICINE

*Professor of Preventive Medicine and Director, School of Public Health and Tropical Medicine, UnivGrsity of Sydney, N.S.I".

WPRO/SOC.PREV.MED./3 Page 1

INTRODUCTION

WHO has chosen an especially pertinent tine for the study of the teaching of social and preventive nedicine in our region, for the subject is a pressing one, both for new or developing schools which have the task of fashioning schemes suitable to their cOJllIllUnities, and for the older institutions, whose courses are often outr,nded and in need of reoodelling. In many centres discussion of this subject forms part of a wider reconsideration of medical education generaJ4r, end one would expect that few schools, at the present time, are thoroughly satisfied that their teaching has been properly ,adapted to the requirements 0 f a changing world. Since proficiency in preventive and social medicine depends on the general educational standards of the medical school, and especially since it should, by its nature, be interwoven with many other subjects of the medical course, a review and reorganisation of the whole nedical curriculum cannot fail to be of advantage to this subject. ,Indeed, in many older schools, nothing short 0 f a remodelling of the whole curriculum will satisfactorily provide for the adequate teaching of preventive an:! social medicine.

GENERAL CONSIDERATIONS

Each country in the Region has its or,n particular health problems and' requirements, and social characteristics, which should be reflected in the teaching cif its schools. But, from the widespread discussions of recent years, and especially from those fostered by WHO, it is possible to set out some broad considerations on the teaching of preventive and social medicine, which, though arguable in detail, are more or less general13 applica b1.e : (a) The course in preventive an d social medicine should be established in the case 0 f new school:, or reorganised 1n the case of older institutions with outmoded teaching programmes, to conform with the social changes and scientific advancement of the present day. Local needs. Though based on solid principle, and forming an essential part oftha student's education, ihe course should be adapted to the living conditions and community needs of its own country, in both the preventive and social aspects of the subject. 'lhe nature of the principal health problems, together with such factors as the social, political and econo~ic structure of the countr,y, and its traditions, organisation and resources, will then necessarily form its background. Educa tional13, this clothes the underlying principles with the interest of reality, and practically, it furnishes the student, apart from any technical considerations, with a valuable knowledge of the conununity in which he will subsequently 'l{)rk. Uniformity. Uniformity between the courses of various schools is not necessary, an d in fact is disadvantageous. For apart from desirable variations due to differing national 0 r community backgrounds, some degree of exper!mentation should

(b)

•

(c)

Wf!ftO/soc .PREV •MEn • /3 Page 2

~..

1mentation should be introduced, as a general rule, into every course. Only in this way can ihe possibilities of subject and method be satisfactorily explored. (d)

Technical training_ It is often held that, in undergraduate public health teaching, technical details should be kept to a minimum, 00 d studies limited to 1I1e considerations of principles. But in many countries conditions exist which render the acquirement of certain technical detail by students as important to their subsequent practice as comparable detail in clinical IOOdicine. Examples of this exist in countries where a pertinent part of the preventive field work is entrusted to rural general practitioners, rather than to specialists ~o have received postgraduate training in the subject. Here the undergraduate course will, of neceSSity, provide stwents with the required training for their subsequent public-health duties. Relationship of ur¥iergraduate and postgraduate facilities. Under circumstances noted in the foregoing section, mere the study of technical detail I1Ulst farm SallE rele?ant part of the undergraduate course, the curriculum will necessarily be influenced qy the postgraduat e training in public health which is locally obtainable. In places where hygiene services are well developed and manned qy spec:ialist personnel, am adequate postgraduate facilities are availal:il.e for the training of these, technical detail will be less important in the undergraduate curriculum. Its extent will vary with the liability of no ~specialist practitioners to be called upon to be responsible for such services. For instance, on the subject of excreta disposal, in SOllE countries it may be necessar,y for undergraduate students to receive only the broadest prinCiples; in others, perhaps, detailed knowledge may te limited to practices suitable for limited rural and camp conditions; while in others again both theoretical detail and experience ~ be desirable to enable the student, on graduation, to carr,y out the duties of a community health officer without further training. Vit1le undergradwt e studies in all schools will necessarily deal with pr.i.nciples and basic facts, discussions based on local needs must be made for each subject of the course, i f full value is to be obtained •.

(e)

(f)

Rev:i4:lon of Courses, 'lhe rapid present-day changes in scientific "kiiOWledge and social ideas render it essential that year to year revision, in both content am IOOthod, should be undertake::! in preventive and social medicine courses. It has lon(; been observed that, in al~st all schools, undergraduate teaching follows far behind not only advanced thought, but usually current practice as well. Constant review is therefore necessary from the point of view of curriculum content. But it is desirable no less for reasons of possible improvelOOnt in the organisation and teaching methods of the course. 3. THE PROBLEM OF CURRICULUM lMPROVEMENT

In a newly· established school, with an informed Faculty Which is aware of the importance of adequate edUcation in preventive and social medicine and is determined to establish this from tm outset, curriculum organisation is relativeJ¥ easy. If unwarranted regard is not paid to old-fashioned ideas, and local needs, problems and conditions are given full weight, such a school may be raised, from tm beginning, to an enviable posi tio n in regard to the teaching ~ this subject. It is •••

•

WPRO/SOC.PREV.MED./3 Page 3 It is in the older medical schools, many with deservedly great reputations, that axtrerre difficulty is likely to be encountered in adapting the course to oonform wtth present day ideas and ideals. Such difficulty is likely to arise, even whe re the Faculty is aware of the importance of improvement. For changes such as increasing the time allotted, and dispersing the subject, fro m its aggregation in a single year of the course through several years, have obvious difficulties which are not easily resolved. Indeed, the crowded medical curriculum, with numerous subjects fighting for increased recognition and the bulk of knowledge ire reasing each year, ensures that in many schools the orgalisation of treventive and social medicine will not be adequate for an indefinite time to come.

The ultimate hope for a thorough rehabilitation of the courses of such schools rests, of course, in a compJe te revision of the medical curriculum. ']his is pOSSible, in a short time, in countries where the need is pressirg am medical education is under the administration of a national body. But it can be assumed, in many cases, that deSpite awareness of the need for general ref;r m, any s weeping changes will t aka time. For this reason it is essential that limited facilities Should be used to every advantage. lo1uch has been done by the curtailment of outmoded studies and by correlatio n of studies with those of other departments. The latter presents opportunity for combining social and preventive teaching, in hospital, institution or home, with that of such departments as medicine, child health, obstetrics and psychiatry. Apart from this being one of the most desirable teaching advances pOSSible, it has the additional advantage that it may possibly be arranged without inroads being made upon the limited teaching time of the department.

'1HE CONTENT OF '1HE CURRICULUM

Apart from the teaching of preventive and social redicine within its special <iepartrent, to be fully effective, it must be woven into the fabric of all clinical subjects by the teachers 00 ncerned. But reference is restricted here to courses which a re the responsibility of the department itself. The ultinBte aim is the inculcation of principles for the maintenance 0 f health and well-being, and the prevention 0 f physical am mental disease in individuals" families and communities, with due regard to the living conditions and social am economic background of the people concerned. Since schools should adapt their curricula to the needs and conditions of their own communities, these will nrecessarily show wide variations. Fo r this reason, it is of value, for the convenience of discussion, to attempt some cBssification of tvpes of curricula" even though these do not lend themsel ws to clearcut grouping. The following, modified from previous \flO discussions, depends on health, economic and other oonditions p"rtaining in particular countries" which shouJd be reflected in curricula a

(a) services are Here improvement

WPRO/SOO.BmT.MED./3 Page

Here improvement 0 f the national health depends directly on adequate training in preventive JOOdicine, whi~ should be stressed throughout the JOOdical course. Enphas is must be placed on environmental hygiene and sanitation, am sufficient t:im3 allotted for 1:1 boratory work and field training and expe rience. The combination of family medical practice with haith officer's duties, which may be required of doctors througout the rural areas, makes it requisite that undergraduates are proVided with adequate technical detail, as well as publichealth principles. In addition, the possibl£ absence of public-health laboratory facilities, outside the cities, may require a mrking experience of laboratory rrethods applicable to public-health practice. Provision must be made for special local requirenents, such as malaria control arxl nutritional problems. 'ilie possible absence of local postgraduate training facilities in public health rerxlers thorough undergraduate training essential. 'ilie use of rural health centres for training in both preventive and clinical medicine, is a valuahle adjunct, especially i f adequate periods are allotted for attendance in the 18 ter years of the course. The further requirement of a period of intemship, in such centres, could be a further valUable introdu::tion to practice. TIlroughout the curricultUn it is necessary that teaching should be especia lly referred to national progranmes far tb3 development of health services, arxl for the eradicaUon of major health hazards. Particular interest attaches to discussion of curricula of this type, in regard to t:im3 allotted, am placing of studies throughout the course, as well as to content and ne thode

(b)

Countries with cOmPrehensive health and social services, and health laboratory services, and in which the najor public-health work is perforned by specialist officers, for which postgraduate training is locallY available. 'ilie responsibility for environlTEntal hygiene arxl sanitation being in the hands of speCialists, with adequate laboratory facilities, there is little requirement for the teaching of technical detail in these SUbjects. Practical work in public-health bacteriology and chemistry is also not required in the undergraduate curriculum. On the other hand, a knowledge of occupational hygiene, industrial medicine, and industrial health services, is necessary. Mos t courses of this type ha ve developed fro m "the old public-health courses, which referred almost entirely to environmental hygiene and sanitation. ThGse have been IOOdified, to a greater or lesser degree in var:iDus places, as community needs changed, as emphasis was removed from

communicable diseases, • • •

...

WPRO/SOC.iRBV.MED./3

Page 5 communica tiLe diseases, and as health services broadened and social services developed. Studies are frequentl¥ concentrated in one year of the medical course, and in many schools sufficient tine is not assigned. 1he mst fruitful developments, apart from the general introduction of social and economic considerations as a background to health studies, are the integration of teaching with that of clinical medicine and other clinical subjects, various e:h'Perim:mts in providing experience in family and community health care, and the use of student health services as teaching adjuncts. The following is the syllabus 0 f the University of· Sydney course, which consists of 50 lectures, and visits to places of public-health or imustrial interest. Studies are aggregated in Fifth Year (of a six year course).

1. 2.

The history of preventive and social medicine. Environmental hygiene am sanitation. Housil'€ and living conditions and the public health. :;ater supplies, emergency sterilisation methods, purification of small supplies, swimming pools, water-borne diseases. Excreta disposal, with special reference to rural and camp sanitation. Food-borne diseases, food poisoning, hygiene of public eating plnces. Milk-borne disease, pure milk supplies, pasteurisation. Ventilation, overcrowding, air-borne diseases, control of insect vectors and rodents.

Health and welfare services, medical care, etc.

WHO and international health. Comroonwealth Health Department organisation, the comprehensive health scheme: medical benefits, pharmaceutical and hospital benefits, maternity and infant endowment, age, inval id am widows l p9 nsions, tuberculosis control schaDe, etc. State Health Services - organisation and responsibilitiee. Local Health Services and the Medical Officer of Health; voluntary health bodies; social health workers. Duties and •••

WPRO/SOC.PREV.MED./3 Page 6 Duties and resp:msibilities of the doctor in regard to national and comrm.mity health and his place in the field of social .~lfare (associated ..lith courSG in Medical Ethics).

4. 5. 6.

(}}ild lo1eliare - State and Municipal Sel"rices; \-relfare centres, preschool and school health care; accidents in thE home. Mental hygiene; mentalJ.y hao::licapped children.

Problem of old age, including welfare, accommodation, medical care.

7. Problem families; alcoholism, delinquency. 8. occupational health; local io::lustrial hazards; industrial heal th servjc es. health educa tbn.

9. Marriage guidance; 10. 11. Nutri ti:m.

Epidemiology and control of CO!lllllunicable dise".ses; epidemiological methods; specific preventive lOOasuresj national control schemes; cross infection in hospitals; preventive medicine in general practice; preventive medicine in countr.y practice; problems of tropical areas. Public-health aspects of certain diseases: e.g. cardiovascular disease, cancer, rheumatism, diabetes, obesity, etc. Inheritable defects. Statistics. MeasurellElnts of health, including main causes of mortality am morbidi"!iv; presentation of statistics; population trends; samplinf.( problems; standardised death ratbs; life tables, etc.

12.

13.

While this course as outlined appears sntisfactor.y for local puzposes, it has failed, on the practical side, to arrange adequateJ.y for student experience in health projects and famiJ.y lilcdical care, beyond thG school e.nd hos;:>i tal. Difficulty in such arganisation is inherent in le.rge schools - there ar~ 1800 medical undergraduates in all y~ars the larr.e numbers catGred for slowing d6velopIll6nt in truse desirable features. On the other hand, a social and preventive outlook is apparent through~ut the clinical teaching, correlation of studies and inter-departmental liaison has been effected, and in various revisions of thG course, other departments have assumed r,;sponsibility for subjects, or parts of these, rreviousJ.y dealt with by the Departnent of Preventivo and Social. Medic ine.

(c)

Curriculum •••

.. WPRO/SOC.PREV.MED./3 Page

(c)

Curriculum intermediate between (a) and (b) •

•

An intermediate type .)f course my be required for stages of development between (a) and (b). Courses of this type also exist in some countries with comprehensive health and social services, and in which the emphasis has passed from communicable to n~n-communicab1e diseases. In these health policy requires the utilisation of non-specialist doctors f~r the maintenance ~f rural health services, this work being combined with curative medicine. In such courses emphasis remains in regard to detailed undergraduate training in environmental hygiene and sanitation and knowledge 0 f laboratory procedures is also requisite. Experience in rural health centres, and other public-health service assignments, also remain as valuable t.raining measures. .

'!HE CLINICAL APPROACli

In most sdnols emphasis is placed :.n the importance of the integration of clinical and preventive and social IlEdicine, as on the desirability of the pcmneation of the latter throughout the medical course. Experimentation on IOOthods of implementing this development is widespread and diverse, aoo forlll3 one of the most interesting features of the current teaching in the subject.

•

It can be said that until adequate integration with clinical studies is achieved, preventive and social medicine will not make their proper impact on medical thought ani practice. Indeed, the achievement or ultimate success in this process should result in the absorption of a great part of the formal teaching of these subjects into that of clinical and other departments. In many schools this has already advanced to a pertinent extent, and what is perhaps evon more important, social and preventive ideas have imperceptibly pervaded the teaching of clinical SUbjects. Apart from its basic importance in broadening the application of preventive and social ideas to medicine generally, this development also results in the awakened interest of students, which tends to be absent from formal courses. The value 0 f preventive madicine becomes more obvious to them when it is placed in closer relationship with the teaching of clinical medicine, and its study is revivified 1:u 111e hUllBn . contacts it c31sequently shares with the latter. The aim of integrating these studies can only be achieved b,y the collaboration and participation of the clinical teachers themselves. It appears that the main service of the Department of Preventive and Social Medicine in this is one of indoctrination, collaboration" and close liaison with these. Participation in the instruction of clinical departments Qy teachers of preventive and social medicine forms a valuable and 0 ften welcome in troduction, but must be regarded as essentially a means to the ultimate errl of relinquisbing the field to the clinical teachers themselves. Valuable advances •••

. WPRO/SOC.PREV.MED./3 Page 8 Valuable advances are possible from periodical discussions, either on a formal or informal basis, between the Department of Preventive and Soclal Medicine ani other departments. By this means it can be ensured that subjects are satisfactorily treated and studies correlated, and that possible collaooratio n between departments is explored. !JruJEdiate advantage is to be gained in the case of certain departments in whose teaching social co nsiderations are obvious ~ displayed. For instance, the Department of Child Health, with its interest in child welfare schemes, baby health centres, institutions for handicapped children and so on; obstetrics, with antenatal and maternal care, puerperal infection etc.; and similarl¥, the Department 0 f Psychiatry. This applies also to certain subjects of the medical course, as tuberculosis, venereal diseases, rehabilitation, and others in which corrulation of teaching can be immediately ensured. The clinical approach is effectively implemented b,y training programmes in which the clinical and social or preventive aspects are pres8Qted side b,y side, ani in which the student receives first hand experience. A multiplicity of such schemes have now been introduced, or are umer trial. liroong these only the following will be mentioned: bedside application of social and preventive roodicinej the study of home and working environment of personal cases; assignments to a general practice, group practice, health centre, rural health centre, health district; participation in "the work of a student health service; investiga ti::>n 0 f public health pro blelllB; home surveys; home visiting with health cr social v,orkers; and assignment to special instituti:ms, as baby health clinics, old people1s homes, child guidance clinics, industrial health units and schools for handicapped children.

•

THE CONTRIBUTION OF O'nIER DEPA,~'OONl'S TO TEE 'lEACHING OF ffiEVENTIVE AND SOCI1.L MEDICINE'

The healthy development 0 f }r eventive and saciLll madicine is towards each medical department accepting responsibility for its emphaSis and teaching, as far as its own work is concerned. Only in this way can the subject satisfactorily permeate all medical studies ~nd achieve its fuil value. The imp'ortance of collaooration and liaison between the departments, am the correle. tion of studies, has been previously mentioned. Additi::>nal reason for the participation of 0 ther departments in the teaching also exists in schools where insufficient te'lching tiroo is allQtted to 1he subject. It is not proposed to explore the extensive possibilities of such participation. But indication of some of the fields in which this has occurred in one particuJa r school, will serve t::> mow the value of such a tram: Department of Child Health: infant '-Elfare am child nutrition, forrrerly taught in preventive medicine, are now mainly assumed b,y this department. i. course in s::>cial paediatrics f::>r fifth year students lias recently been instituted, "lith instruction which includes child development, family and social influences, problems of •••

...

•

WPRO/SOC.PREV.MED./3 Page 9 problems of childhood, and governmental and other agencies concerned in child welfare. Institutional and hOllB visiting experience, with personal study of children in their horne environnEnt, is associated. Department of Obstetrics: prenatal and maternal care (former~ treated in part with preventive llBdicine), puerperal infection, cross infection in maternity hospitals, 2.00 s ex hygiene have been adopted, though the principles of some of these subjects form part 0 f th e course in l.lreventi ve madic ine. Department of Psychiatrr: This recently reorganised department now ptlces particuJa r emphasis on mental hygiene, and ismpid~ taking over instruction previously given with social and preventive medicine. It aupplellBnts its previous mental hospital teaching lrli. th the l:edside study 0 f m; nta1 states 0 f lesser degree in general hospital patients and a special departmental officer is being provided for this purpose in each technical hospital. Experience in child guidance clinics has been added. De artment 0 f Medicine and Sur e ,Tho use of almoners and socia workers in routine med~ca teaching is fir~ established throughout clinical schoo]s, fol10'Wing early emphasis by the Department of Preventive and Social Medicine. Discussion of th3 use of general practitioner services and group practice for the extension of stUdent clinical instruction is under discussion. Statistics: Elementary statistical llBthod, introduced in too teaching of vital statistics in this department, is now carried out in preclinical teaching. Tuberculosis: A clinician of the Department of Medicine, with special experience in do~~ciliar,y practice and community control measures, collaborates with the departnent in the teaching of tuberculosis control. Karriage Guidance: A. teacher f~m the Departnent of Gynaecology, experienced in the medical aspects of marri'lge oounselling, collaborates on this subject.

WORLD HEALTH

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./4 27 August l.957 ORlnINAL: ENGLISH

AND PREVENTIVE MEDICINE Manila, Philippines 16-29 October 1957

STUDY GROUP ON SOCIAL

ROlE OF THE IEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE IN COMMUNITY HEALTH ACTIVITIES by Chia-chi Ma, M.D.} M.P.H.* CONTENTS INTROWCTION 2

UTILIZATION OF COMMUNITY RESOURCES AS A TEACHING IABORATORY 2.1 2.2 2.3 2.4 2.5 Home Visits and Home-care Programmes Comprehensive Heal.th-care Programmes The Visit of Observation Participation in Community Surveys Student' ,Participation in Direct Hea.l.th Activities

3 5 5 5 7

3 4 Annex I

ACAIEMIC DEPARTMENT AND COMMUNITY HEALTH AGENClES CONC~ION

References

*Academic Dean, National Defense Medical Centre, Ta.ipei, Taiwan

l/Poo/soc.PREv.hED./4 Page 1 1. IN1RODUC TION

There are numerous points 0 f contact between a medical school and the community in which it is situated. The school graduatesophysicians*, some, or lIXlst of whom serve the community in one capaci"\u or another. Its teaching and affiliated general hospitals, together with their outpatient departments, offer ~0rtant medical sl3rvices to the community besides their teaching function. The ronmunity Clfficial and voluntary health agencies may resort to the medical school staff for consultation or participation in planning, or for purposes of conducting surveys and studies. Heciprocally, the community itself serves a most useful purpose for teaching medical st~ents especially in social ar:d preventive medicine.** It is a laboratory for the observation and study of the social and environmental factors of health and ill-health2 ,3 and the methods and resources of the connnunity in meeting the needs that have arisen for the prolOOtion and maintenance of health, a.Ild tm pre vent ion, diagnosis, tf'ea tne nt am rEhabilitation of ill-health. 4 There is need for the student to be acquainted with the role that the various agencies play in community organization and affairs, ar:d he must learn how to ut;i.lize them to achieve his goal of meeting the health needs 0 f his patients.!) In this two-way relationship between the medical school and the community, the departllSnt 6 of social and preventive nedicine plays or should play a significant role. The collaboration by the department of social and preventive llBdicine with agencies and 0 rgOanizations outside th6 faculty, or even with other fa culty departments, is of a tind unusual elsewhere in IIEdical education. It was brought out at the stu:l.y conference in Nancyl that "for nany purpOS6S the departllSnt is dependent on materials primarily under the control of others. The laoora tory of social ma:iicine lies outside the teaching department, in the homes and l-iOrkplaces of the people; health and medical-care services are operated in the community; clinical social medicine is practised on patients under the care of family doctors and medical and surgical specialls ts. 1I The Conference was therefore cognizant of the principl" that lIbecause the teaching which begins at the bedside extends through a wide range of services into every aspect 0 f community life, collaboration outside the faculty is essential. 1I ,Due to the ...

* Some schools may admit also dental, nursing and other students of collegiate ]a vel.

The 100 no graph on The Teaching of Hygiere ar:d Public Health in Europel employs the expression "hygiene and preventive and social medicinel! vilen referring to the subject matter usually included under the headings of public health, social medicine, preventive ma:iicine, hygiene, and epidemiology in teaching pr~ctice. The department that undertake s such teaching is referred to GO the "department of hygiene am preventive am. social medicine." In the present paper, the tOrIn "socialand preventive medicine" mll be used instead.

WPRO/SOC.PREV~ilm~/4

Page 2 Due to the scope of colWlunity services provided by countries Ylhere the present cerrtury has witnessed the developl1l3nt of personal services within the fral1l3mrk :Jf public her.lth, the large-scale :Jrranizatbn of medical care, the developllEnt of industrial-health services, and the provision of a multitude of social service and insurance schemes, the Conference also noted that collaborat1.o n wi th a~ncies outside the faculty, once confined to sanitary matters, has been enlarged to include a wide range of personal preventive and prom:)tive services provided by a variety of official and unofficial bodies with which the student needs to be familiarized. '!his situation is as true in a few highly industralized areas in the \iestern Pacific Region as in the many European countries to which the above statement applies. 2. UTILIZATION OF CCIlMUNITY RESOURCES AS

'lEaCHING IAOORATORY

For extr'-mural teaching of social and preventive medicine, the community and its resources may be utilized through home viSit, visit of observation, and participation in some of the community health activities. 2.1 Home Visits ani Home-care Programmes

Occasional home visi ts made by students for the follow-up of clinic patients with social-service workers or visiting nurses, are a means of providing contact outside :>f the "Ialla of the hospital with SOnE families in the community for the observation 0 f the effect of SOCial, economic, and psychological factors 0 n disease, and of the community resources available for the s:>lution of their problems. The educational value of such visits would be enhanced i f stUdents had the opportunity of discussing the problems discover3d with nEmbers of the staff. Home delivery service could be utilized as source material for medicalsocial teaching. MentiJn has been made of a medical school in tle United states in which a faculty member with combined appointl1l3nts in the Department of Public Health and Preventive Medicine and in Obstetrics and Gynecology permit ted him to foster the teaching of the social aspects of obstetrical care. 5 Where extra-mural te',ching ext"nded throughout the duration of the medical course cannot be undertaken by a sOOJol, regular hJme visits for an academic term or year have been adopted in conjunction with a didactic course on social and preventive medicine. Mention might be made of such weekly visits undertaken qy medical and dental students at the National Defense Medical Center, Taipei, Taiwan, for a period of 18 weeks during their initial clinical year when an introductory course on social medicine is given. Each student visits an aSSigned family fJr two tJ four hours every Saturday afternoon after preliminary arrangement has been made with the family by the instructor in charge. Class discussi-:Jn is held two hours every other week in the presence of the entire academic dopartment staff, one of whom was trained in social anthropology. Definite interest in these visits is shown by about a third of the group. It may be p:>ssible to extend this plan to permit some 100 medical and dental students every year to follow-up the same families over a period of four years to maintain continuity, but •••

WPRO/SOC.PREV.MED./4 Page 3 continuity, but additional staff would be needed when the number of participating students and families is multiplied four-fold. The same quantitative problem confronts many medical schools in Europe. It was mentioned at the Nancl conference that even in countries where homenursing services and public-health services are well established, practical difficulties of making arrangements of a highly personal character for large numbers of students stand in the way of their use for teaching purposes. l On a broader basis, examples can be cited of several medical schools in the United States that operate domiciliary medical services for the indigent and medically indigent in their immediate neighbourhood.7 The Department of Preventive Medicine at Boston University School of Medicine is in charge of such a home medical service for a population of 50 000 entailing 15 000 home visits annually. These visits have been made for fourth-year students and some degree of cotinuity of patient care is maintained. Patients who are hospitalized are followed by the referring student and reported on periodically throughout the month spent at the service. One distinctive feature of the programme is that the student nurses, the &edical students, house officers and student social workers are trained together. Another example brought out at the Colorado Springs Conference7 was the home-care medical programme at Richmond, Virginia, where a health department service programme is conducted in co-operation with the Medical College of Virginia. The college assigns its senior medical students to the programme. Each student spends from 18 to 20 days in this programme and makes home calls under the supervision of residents and faculty members. Outpatient care is also provided. These home-care programmes give students a supervised extra-mural experience which sharpens their appreciation of the effects of people's way of living on their health, and gives them practice in working closely with a variety of professional personnel. The Conference was aware, however, that such programmes were not primarily designed to provide or demonstrate continuity of patient care. Several university fBmily-care programmes* were described at the Conference which provide health and medical care for selected family groups over a continuous period of time. Here, it was stated, the student sees individuals of all ages, whether healt~or sick. He gets to know the health needs of a whole family, to appreciate the effect of the family situation on the individual's health, to mature in the patient-physician relationship, to see ways of applying early preventive measures for the presumable well members of a family, to learn the difficulties of providing care for the chronically ill, and the importance of rehabilitation. 2.2 COmprehensive· Health-care Programmes

There has been a growing conviction that to give medical students a real understanding of the people they are being trained to serve requires the acceptance by medical schools and hospitals of a re~onsibility for making comprehensive service available to all sections of a community.9a

* The

family-health advisory service at the UniverSity of Pennsylvania8 and at the Cornell Medical College, a family-care programme at Boston University that operates within the framework of the home medical service mentioned previously, and a similar pr05ramme at the University of Tennessee.

WPRO/SOC.PREV.MED./4 Page 4 An example of comprehensive care to patients is that at New York University where a limited number of fourth-year students participate in a medicalservice plan through group practice and volun~y insurance associated with the Health Insurance Plan of Greater New York. Here, teaching is conducted in conuection with patients from outside the ranks of the indigent population. The Cornell Pro gramme 10 mentioned previously is one that aims at the teaching of comprehensive medical care as a'oon-departmental activity of the New York Hospital-Cornell Medical Centre with the participation of the clinical departments and the Department of Preventive Medicine. A public-health nurse provides liaison with community nursing agencies. There is also a social work co-ordinator. It is believed that students actually learn more rather than less scientific medicine. Two other examples of a comprehensive-care programme for a whole population unit in the United States are that of the Hunterdon County Medical Centre in New Jersey~erving a population of 44000 and where studeniB are sent by three universities,ll and that of the University of Oklahoma. 12 The latter programm~ covering six counties in the State of Oklahoma, was stated to be an experiment in community liaison, an exercise in preventive medicine, a teaching experience in continuity of care, and a demonstration of the value of affecting communication between physicians and community resources. It was also believed that the importance of social and environmental ~ctors in medicine stands out in best relief against such a comprehensive framework. Mention has been made by Taylor13 of a comprehensive programme of family care developed by the Department of Family Practice of the medical school at Durban in South Africa. A further step in the organization of comprehensive health care is regionalization of health-care service. A detailed discussion of comprehensive health care and medical regionalization is beyond the scope of the present paper, but it might be pointed out here that the concept of medical regional1zation is embodied in the planning of most welfare states, that regionalization in the United States and elsewhere has not yet been ext~usive,* and that there is apprehension among some medical educatore.and clinicians in the United States as to the desirability of extending the medical influence of a university into the community for more effective teaching of clinical and preveotive medicine without sacrificing the ~uality of teaching scientific medicine. l5a The viewpoint of the advocates of the holistic approach to the problems of man and his health and ills can best be summarized by George Packer Berry's statement: "Scientific medicine must become comprehensive medicine, yet not become thereby any less scientific." Scientific medicine must become comprehensive medicine for ancther reason in areas where the dearth of professional personnel is acute and where manpower can better be utilized in a comprehensive service that integrates both clinical and preventive medicine. 2.3 The Visit

.t.

* The ~~nning of a regional programme in Michigan, U.S.A.,9b and in Puerto . Rico might serve as a usefUl reference for similar planning elsewhere.

WPRO/SOC.PREV.MED./4 Page 5 2.3 The Visit of Observation In Europe, the visit of observation covering the entire field of social and preventive medicine is considered the commonest teaching procedure involving collaboration between the academic department and extra~mural agenCies, and has an~ablished place in the teaching programmes of allost every medical school. It is believed that schools in the Western Pacific Region employ the same procedure in requiring students to visit health establishments, sanitary installations, personal health and welfare services, industrial medical and welfare services, and rehabilitation agenCies, where these services and agencies are available. The educational value of such visits depends on the degree of student supervision and the opportunity provided for discussing the observations so made. Such supervision is liable to be inadequate at the time of visit if there is shortage of staff and if students are not prepared beforehand and are not mature enough to appreciate what there is to observe. If brief'ing is given by members of these establishments or services, there is the possibility that it may be given from the standpoint of the "specialist" - a defect shared no less by some lectures - rather than from that of' utilization by these students in their fUture practice. Like audio-visual aids, the visit of observation is a supplementary method of teaching which could serve a usefUl educational purpose, particularly in the absenCe of other extra-mural activities, if properly integrated with the over-all teaching programme. 2.4 Participation in Community Surveys While, students may take part in university or community-sponsored health surveys, more frequently, however, students are required to submit a detailed report on the organization and health problems of a specific community either as a graduation theSis, where such is required, or as an exercise in social and preventive medicine. In either case, it is desirable that the community be first approached by the academic department. The University of Amsterdam l offers an interesting example of the use of an elective dissertation on some field observation as an alternative to the written examination in social and preventive medllcine. The writer was particularly impressed by the care and thoroughness with which community surveys were undertaken by undergraduates of the UniverSity of' the Philippines College of Medicine, Numerous other examples can be given of surveys of this nature which are often performed during the summer recess. 2.5 Student Participation in Direct Health ActiVities Participation by the student in the activities of local health departments or voluntary health agencies as part of undergraduate education is not as extensively used by the academic department as is the visit of observation. It is assumed that schools which do not favour such a procedure would consider this as belonging to the realm of post-gradua.te education. lack of time in a crowded undergraduate curriculum is probably another deterrent factor while administrative •••

WPRO/SOC.PREV.MED./4 Page 6 administrative difficulties may also stand in the way. Where such participation is undertaken, it is generally the department of social and preventive medicine that makes the necessary arrangement with the collaborating agencies. In Yugoslavia, where comprehensive regionalized heat~ service facilities have been used for co-ordinated experience for students, all medical students at Zagreb are required to have four weeks' field practice at the end of the third year. l The teaching unit for this purpose consists of a team of six students, with a junior teacher as leader. The teams are sent out to districts where they work with the local physician and the medical officer of health. Discussions are held by the faculty both before and after the field practice. In the sixth year of studies, students are attached to a health centre for a period of six weeks to obtain a first-hand acquaintance with the health services in Croatia. In India, villAge health centres are u~~d as teaching laboratories by several departments of preventive medicine.-~ Students learn principles of sanitation by actually working on simple installations in the homes of villAge families. PartiCipation in the work of health centre dispensaries as part of their medical outpatient service in clinical years eti&bles students to learn how preventive measures can be applied in general practice. They also work in various tj~es of health clinics and observe public-health services. At two Christian medicsl colleges, arrangements are made for students to . have part of their clinical work in a small rural hospital which is part of a health centre. Under the University of Oklahoma comprehensive medical-care programme12 mentioned previously, students partiCipate in the activities of one of the co-operating health departments, two to three students at a time for three consecutive days. Particular emphasis is placed on visits in the field with public-health nurses. Time is also spent in health-department clinics and the philosophy and value of these to the community is stressed. In another way the student may utilize the resources of the local health department for background information on patients he is about to visit, or discuss with the department on ways of handling a situation which he has discovered during the course of his visit. other examples in the United States are provided by preceptorship programmes. In nine of the 17 programmes discussed at the Colorado Springs Conference,7 the student is associatad with a general practitioner and is given a chance to see the broad aspects of general practice. The other eight programmes provide experience under a preceptor either in a group practice clinic, with a public-health agency, in industrial hygiene, or in a small community hospital. The duration of service varies from two weeks to three months, mostly during the senior year or the summer preceding it. It might be mentioned in retrospect that a plan of operations adopted by the Department of Hygiene and Public Health of the Peiping Union Medical College, Peiping, China, from the '20's to the '40's* could be duplicated elsewhere. The college supported a health station which was operated as part of the city health department and which covered a population of 120 000. A system of public-health clerkship was instituted and it required senior medical students •••

/ I

Information on the present status is not available.

WPRO/SOC.P.REV.MED./4 Page 7 medical students to spend a month with one of the health services. The alternative was a similar period of time with a co-operating rural-health centre operated elsewhere in the province. 3. ACADEMIC IEPARTMENT AND COMMUNITY HEALTH AGENC:m3

Besides collaboration for extra-mural teaching of undergraduate students, the department of social and preventive medicine of a medical school has other points of contact with official and unofficial community health agencies in a two-way relationship. In Europe, teaching of hygiene or public healt~ was at one time a part-time responsibility of local health officials. 3 But the pattern was changed in Europe and elsewhere as independent academic departments were established and as more full-time faculty members became available. Still when the need arises, especially in areas where there is shortage of professional personnel in general and of health personnel in particular, concurrent appointments by a health agency and a medical sCbool may be the only or the best solution under certain circumstances. ,/

The fact that the chairman of the Department of Preventive Medicine at the University of Oklahoma is also an active working member of the State Health Department, and that health officers participating in1his programme have been given faculty status at the medical school, must have contributed materially to the suc~ss of the comprehensive medical-care programme mentioned previously. It may happen sometimes that particular needs have to be met extramurally even though shortage of staff might otherwise preclude such a possibility. The National Defense Medical Centre in Taiwan, for. instance, was faced with this dilemma when an opportunity presented itself for the use of a nearby rural community of 20 000 population for teaching pw:poses. The distrct with a poorly-staffed health station, is being developed by a training institute which is also interested in community development, but is acutely in need of medical leadership. The Medical Centre has for years been looking for a suitable practice field for its students, and, despite its own shortage of staff,* has decided to assign one faculty member** to take concurrent charge of the health service with dual appointment by the local government, and a sanitary engineer and other members on an ad hoc basis. There is

...

Four senior and five junior faculty members, with a senior public-health nurse from another department, undertake the teaching of social and preventive medicine to over 900 medical, dental, nur!3ing, and pharmacy students and some 500 in-service officers and men. Former fellowship recipient of the World Health Organization.

WPRO/SOC.PREV.MED./4 Page 8 There is a growing feeling in the United States at least that it is desirable to keep faculty members in soci~l and preventive medicine currently up to date on community health practice, It has been asserted that for a teacher to keep one foot in the field through active association with progressive health a0Sncies is an advantage that cannot be over-emphasized. He needs the same kind of clinical experience as does the professor of surgery. It has been suggested that this e:aperience may be extended during non-classroom periods and by sabbatical leave. This is a function that is incumbent on the community health services in assisting the academic department. The possibility ofaltarnating between full-time teaching and full-time practice of public health has also been suggested and the idea ~s recently been put into practice in one institution in the United States. Participation by members of the department of social and preventive medicine in community health activities may also take the form of temporary or semi-permanent consultant posts, or memberships in health councils, health boards and advisory committees, in which capacities these members can make valuable contributions to the planning and organization of community heali~ and medical-care programmes, and to the field of public-health diagnosis. By far the most important of all contributions, however, is that of community research and the stimulation of community action. The latter functions are even more important in countries or areas where community action needs invigorating or is even non-existent. The stimulation of community action is not a simple matter to undertake without a through knowledge of the SOCial, cultural, and psychological factors involved. Academic departments which have followed the traditional pattern of teaching and research may find it difficult to collaborate even with the teaching departments in the same school, or to generate sufficient interest and understanding in these departments to break down some of the barriers that stand in the way of , more effective teaching of social and preventive medicine. Knowledge of social groups, and of group dynamics and group action, largely by way of the social and psychological sciences, is a relatively recent addition to the armamentarium of social and preventive medicine and should be the working basis of research on and collaboration with the community. Needs of the community may require the collaboration of the academic department in the provision of facilities for training special workers'in the various health services, or of refresher courses for purposes of in: service training. In the cbsence of a school of public health or institute of social mediCine, the department may even be called upon to conduct postgraduate education. For closer co-ordination between academic teaching and community health activities, a useful suggestion has been the provision of joint housing for the health department, the department of social and preventive medicine, and the teaching hospital and clinics. This has been put into practice in some regions in the United States. An unusual example there is one in which the e is even jo~nt administration of the health department and hospital. 1 5b

CONCWSION

•

WPRO/SOC.PREV.MED./4 Page 9

CONCWSION

In the present paper, an attempt has been made to gather largely from the literature patterns of extra-mural teaching and collaboration in various countries which illustrate the role of the department of social and preventive medicine in community health activities. The examples given have not been exhaustive and furtGer information on the patterns and thinking existent in the various parts of the Western Pacific Region would be a valuable contribution to the study currently to be conducted by the Wor.ld Health Organization. The divers teaching devices and techniques used in various parts of the world in breaking down departmentl barriers towards a comprehensive approach to the study of man and his health and ill-health mayor may not find easy application in all parts of this Region. Whether some of these ideas can be adopted or adapted or even better techniques may eventually be evolved, a good deal depends on the attitude of the medical educators and faculty and, inllOtie ca~es, the government as well in defining the objectives of medical education in relation to the immediate and future needs of the community, the personnel and funds available in attaining these objectives, and the finding of the techniques and procedures best suited to the conditions of a particuJ.a.r school or area. There is no universal pattern, nor can the pattern of anyone country be adopted in whole by another. There are few proved techniques and procedures that can be adopted by other schools even in the same country without continuous evaluation~And further experimentation. While changes do not necessarily mean progress, there is an obvious need for every institution to find ways and means of correcting the dI~ects resulting from the over-II> ecialization of "scientific medicine", of eliminating the diohotomy that exists between preventive and Clinical llEdicine, and of removing preventive medicine from il~ present position of semiisolation and less than optimal influence. Whether or not comprehensive health care and eventual regionalization can feasibly be applied in this part of the world in the foreseeable future, extra-mural teaching and closer collaboration between the acadeoic department_and community health agencies are measures that are indispensable to the purpose of helping the student to develop new insight and comprehension of the problems of his patients as people, and of the potentialities and responsibilities of his role as a physician. 20

. WPRO/SOC.PREV.MED./4

ANNEX I REFERENCES

GRUNDY, F. & MACKINTOSH, J.M. The Teaching of Hygiene and Public Health in Europe. Orgoanization, Geneva, 1957, MonobTaph Series No. 34

World Health

INSTITUTE OF SOCIAL MEDICINE Social Medicine: Its Derivations and Objectives. Edited by Iago Galdston. New York, The Commonwea.lth Fund, 1949, 294 p. SAND) R.

The Advance of Social Medicine. LEAVEIJ.., H.R. & ClARK, E.G. Textbook of Preventive Medicine. 1953, 629 p.

London, Staples Press, 1952, 655 p. New York, McGraw-Hill Book Co.,

JOINT COMMITTEE ON THE TEACHING OF SOCIAL AND ENVmONMENTAL FACTORS IN MEDICnlE Widening Horizons in Medical Education. New York, The Commonwealth Fund, 1948,. 242 p. Proceedings of the First World Health Conference on Medical Education, London, 1953. London, Oxford UniverSity Press, 1954, 804 p. Preventive Medicine in Medical Schools: Report of Colorado Springs Conference, November 1952. J. med. Educ., 28, 1-123, 1953 HUBBARD, J.P.

6 7

Observation of the family in the home.

mural facilities in medical education. 26-~, 1953

Symposium on ext:aJ. med. Educ., 28,

THE NEW YORK ACADEMY OF MEDICINE, INSTITUTE ON MEDICAL EDUCATION Trends in Medical Education. Edited by Ma.hlon Ashford. New York, The Corrnnonwealth Fund, 1949, 334 p. ClARK, D.A. Comprehensive service and medical education. (In book, NEW YORK ACADEMY OF MEDICINE EDUCATION. Trends in medical education. New York, The Corrnnonwea.lth Fund, 1949) HORNING, B.G. Planning a comprehensive regional programme. (In book, NEW YORK AcADEMY OF MEDICINE EWCATION. Trends in medical education. New York, The Commonwealth Fund, 1949)

READER, G.G. Comprehensive medical care. SympoBi~~ on extra-mural facilities in medical education. J. med. Educ., 28, 34-40, 1953 11 TRUSSEIJ.., •••

·" WPRO/SOC.PREV.MED./4 Annex I Page :2 11 TRUSSELL, R.E. The Hospitaland its relationship to the Community. (In the Transactions of the Third Conference on Administrative Medicine, PrincetonSr.tew Jersey, 1954). New York, Josiah r.t!.cy, Jr. Foundation, 1955, p~ -116 SCHOTTSTAEDl', W. W. & WOLF, S. Collaboration of the Medical School and the Health Department in Teaching Medical students. Amel,'. J. publ. Hlth., 45, 10911100, 1955 -TAYLOR, C.E. The Teaching of Preventive Medicine Around the World. J. med. Educ., )g, 399-409, 1951 GRANT, J.B. Trends in Medical Education and the Opportunity of the University of Puerto Rico. J. med. Educ., 31, 605-612, 1956

Transactions of the First 90nference on Administrative Medicine, New York, N.Y., 1953, sponsored by. the Josiah Macy, Jr. Foundation, New York, N.Y. pp. 132 pp. 162 VAUGHAN, H.F. & GRl'I'ING, V.A. How can we improve our teaching of public health? Hlth., 46, 696 .. 701, 1956

15a

15'0 16

Amer. J. pub1.

AMOS, F.B. & HILLEBOE, H.E. How can we improve our teaching of public health from the viewpoint of the health department? Amer. J. publ. Hlth., 46, 691- 6 95, 1956

HISCOCK, I.V. Community Health Organization. 1950, 218 p. BARR, D.P.

New York, The Commonwealth Fund,

19 20

The Teaching of Preventive Medicine.

J. med. Educ.} 28, 49-56, 1953

SHEPS, C.G. & FLEMING, W.F. Student Participation and S~ervision. Symposium on Extra-Mural Facilities in Medical Education. J. med. Edu., 28, 44-48, 1953

WORLD EEALTH ORGANIZATION

REG IONAL OFFICE FOR TEE WESTERN PACIFIC WPRO/SOC.P.REV.MED./5 29 August 1957 ORIGINAL: ENGLISH

AND MVENTfVE 16-29

STUDY GROUP ON SOCIAL MEDICINE

M3.nilA, Philippineer October 1957

TEE SCOPE OF RESEARCH IN SOCIAL MEDICINE by Alwyn Smith, Ph.D., M.B., Ch.B., D.P.H.*

iWHO Lecturer in Public HeeJ.th, Department of Social Medicine and Public Health, FacuJ.ty of Medicine, University of M:Uaya, Sine;apore.

WERO/SOC.P.REV.MED./5 Page 1 During the past fifteen years university departments including in their titles the expression "Social. Medicine" have been created in nany parts of the world. Discussion of' the precise functions of' such departments has been widely propagated and definitions of their proper scope are legion. While no final definition commanding universal assent has yet been formulated, nor even broad agreement reached, it is of interest that there does emerge a constant theme. M;)st discussions have taken as starting point the agreed view that the health of' hunan communities cannot be f'ostered solely by considering each case of hunan disease as a phenomenon uniquely con1'ined to the body of each patient. Whereas it has been canvassed that "there are no diseases only sick people II , the history of'medicine serves to demonstrate that advances have come from concepts involving the idea of' diseases as entities varying in expression from person to person but having sui'f'icient constant characteristics to justify classification. It follows that enquiry into the aetiology, prevention and therapy of' diseases is most profitably prosecuted not by considering each patient as presenting ~ unique problem, but by examining groups of patients classified according to particular responses to particular pathogenic stimuli.

.."

~ classif'ications of persons are necessarily social, since Classification criteria characterise groups of' persons and a group of persons is necessarily a social. unit. Whether we define a group in terms of its medical attributes and examine other relevant characteristics, or 'Whether we define it by other characteristics and examine its medical attributes (as for example the incidence and type of its disease experience), we are in fact exploring the association of social. characteristics and pathological experience. Thus any classification of a group in terms of both medical and social a.ttributes is an exercise in social medicine enquiry.

In order to enlarge so general a definition so as to demonstrate the functions and scope of socie.l. medicine research, brief consideration should be given to the origins of the subject. The function of clinical medicine is not the study of society but of sick persons. That medicine might have any other scope than the clinic has only recently taken shape as a practical. idea. The pioneers of modern public heal.th were concerned with the protection of communities from epidemic disease and were necessarily concerned with control of outbreaks in populations. The study of population characteristics 'Which favoured or restricted spread developed into the science of epidemiology. It early became apparent that certain aspects of social organisation, particularly at the technical level which we now refer to as the f'ield of etNironmental sanitation, were intinately related to the spread of epidemic disease. However the concurrent development of the microbiological sciences tended to. obscure the importance of the role of social organisation, and epidemiologists turned much of their attention from the study of society to the study of the behaviour of micro-organisms. Since medicine was historically largely pre-occupied with the study of patients, preventive measures began to be sought within the field of immunology and its related sciences. However, in attention became disease. It was discerned within the years which folloWd the triumphs of bacteriOlogy, increasingly directed to the pro~lems of' non-communicable observed that patterns of disease incidence could be communities and that these patterns varied in a way 'Which could be •••

WPRO/SOC.PREV.MED./5 Page 2 could be related to population characteristics. Populations having different types of social orsanisation were observed to show different patterns of disease experience. At the same time the concern of biology in general was being directed away from the description of individual ore,anisms to the study of groups and populations. It became increasingly evident that the organisation of communities had biological consequences on the devaopment of individuals within them. Epidemiologists bee,an again to enquire whether the structure of social groups had a bearing on the prevalence of pathological processes among their members. The prime biological observation concerning man was seen to be that he is a social animal. It was not a large step to begin to extend epidemiological enquiry to the ~ination of the role of social structure in the aetiology, pathology, prevention and therapy of hllJllB,n disease. Social medicine had begun. The scope of social medicine research is within the field of medicine and is concerned with the elucidation of problems arising from the effects of social characteristics on diseases and of diseases on societies. It is a development not of clinical medicine but of epidemiology. It seeks not only to study the effects of social structure on health but also to provide a rational basis for the deliberate manipulation of social organiBat ion in furtherance of preventive and therapeutic efforts. It is limited neither to a preventive nor to a "therapeutic role and covers both aspects of communities t medical needs and efforts. S ince traditionally , preventive medicine has been developed on a community basis whereas community provision of sickness care is of recent development, social medicine bbs inherited a larger interest in preventive than in curative medicine. There is no reason however why it should continue to display this bias. The first essential req,uirement of any university department which is to justify its existence is the development of a research field. Since the creation of the first departments it is probably fair to state that few branches of medicine have demonstrated so active a developnent of research as has been seen in social medicine. Our knowledge in such diverse fields as the aetiology of prematurity, the processes of human srowth, the processes of ageing, the aetiology of cancer, of coronary hearth disease has been enormously extended by social medical enquiry. Whereas it would be impertinent for any one author to attempt to delineate the proper scope of social medicine it may be useful to examine the field of achievement as a guide to what my be reearded as rewarding lines of approach. In its notice to contributors, the British Journal of Preventive and Social. Medicine defines social medicine as follows " ••• that branch of science which is concerned with (a) biological needs, interactions, disabilities and potentialities of human beings living in social aggl'egates; (b) numerical, structural and functional changes of human populations in their biological and medical aspects.... Social medicine takes within its province the study of all environmental agencies, living and non-living, relevant to health and efficiency, also fertility and population genetiCS, norms and ranges of variation with respect to individual differences, and investigations directed towards the assessment of a regimen of positive health." The biological sciences in general and medicine in particular have DOW advanced beyond the early stages of description and classification to the more so:Phisticated problems of measurement and enumeration. Social medicine is therefore now in a position where a rigorous numerical approach is not only possible ••• -

'"'-

WPRO/Soc.PREV.MED./5 Page 3 only possible but necessary. The acceptable observations which form the body of social medical knowledge are of a quantitative kind. It is therefore a prerequisite of an effective study that workers should be equipped at least at an elementary level with the methods of quantitative biometry appropriate t~ population studies. It has been objected that social medicine as above defined is merely another oa.me for medical statistics. Such a criticism merits examination. The methods of social medicine research are necessarily largely statistical. Since statistics is the science whereby we seek to draw rational inferences from quantitative observations on variable phenomena, it is an essential tool in the equipment of anyone who wishes to make such observations or to draw such inferences. That human beings and the societies which they compose are \tl.r.l.able is evident from the most cursory observation. Accordingly if we seek to draw rational inferences from data from this source we must make use of statistical methods. Medical statistics is that branch of statistics which seeks to provide methods for the quantitative study of human disease. It is no more the whole of social medicine than is auscultation (for example) the whole of clinical medicine. Yet we would study clinical me~ne less effectively if we eschewed auscultation. Similarly social medioine cannot be effectively studied without statistics. This should not be allowed to obscure the necessity for the employment of other relevant techniques. Socialmedic1ne research depends on data from human social groups. The whole technique of such observations requires development. Social medicine no more consists entirely in social case work than does it consist of statistics but social case work methods are appropriate to the making of some social medical observations. There has been a tendency in some places for social medicine to be equated with the work of al.moners. But such work is no more the whole of social medicine than is physiotherapy the whole of surgery. The kinds of observations which are elevant to social medicine enquiry include all observations which may be nade on human social groups and "Which have a bearing on the causes and consequences of hunan health or disease. In dealing somewhat more.specifically with the field of social medicine research a preliminary broad classification of original work in the field may be valuable. Such work has been approxinately classifiable under the following heads: 1. 2. Philosophical writing directed tOW6:r:ds the establishment of a set of basic principles defining the field of social medicine; Methodological research "Which has generally been statistical; ditions in ~ diseases arise so as to form verifiable hypotheses concerning the modes of genesis of the diseases in question or to indicate means of control;

3. Aetiological research which has sought to define the social con-

Descriptive reseBllCh which seeks to establish norms and ranges of variation with respect to processes of medical interest whether pathological or physiological; Eval.uative research which seeks to establish the medical needs of different social groups, to a.ssess the extent to which services provide for those needs and to assess the relative merits of prophylactic or therapeutic procedures and organisa.tions as instruments for the promotion of social health. Concerning original •••

WPRO/SOC.PREV.MED./5 PaBe

Concerning oriBinal work in the philosophy of social medicine little need be said beyond referring the reader to the works of Crew, Halliday, Ryle, Sand and others. The creation of academic departments in social medicine which occurred some twelve to fifteen years aBO had been in response to a demand forrecognition that a valid body of knowled.ee and principle had Brown up concerninB the behaviour of disease in society. It was felt by many that despite its orieins in public health and despite the fact that departments of public health were firmly established in most medical schools, social medicine marked sufficiently radical a departure from the current concept of public health as to justify separate representation as a medical science. As with any innovation (even when, as in this case, innovation is confined to recognition at University level of an established discipline) opportunity was afforded for all to air their views as to wtat scope the subject should have. The result has been a confusion which did not exist at the outset but which has been worse confounded by almost every new treatise on the sm ject. It would be difficult now to name a field which has not been proposed as the proper domain of social medicine since a regard neither for semantics nor for history has Characterised many autbo"s. . By contrast the development of a methodology of social medicine has proceeded apace. Perhaps this has been because social me01cine necessarily inherited the techniques of epidemiology from which science it has grown and has been able to adapt them to its own uses or to develop them. The investieational procedures appropriate to social medicine are biostatistics and the field enquiry, which are also basic methods in other branches of human biology. This has enabled social medicine to enjoy the benefit of close contact with developments in these other fields and much traffic both of ideas and of personnel has been evident between the separate disciplines. A major advantaBe to social medicine from this interchange has been that it has been freed from much of its dependence on clinical medicine for basic investisational techniques. If a social med1a1ne methodoloBY had had to be developed from that current in clinical medicine the way to advance would have been greatly impeded since the techniques appropriate to examination of an individual are only to a small extent valuable in the examination of society. However this advantage has not been eained wholly without loss. The accent on the clinic still predominates in medical education and the development of social medicine by methods little known or understood by clinicians has led to a severe breach of contact between clinical and social med1c1oe. To some extent this was of course unavoidable since clincial and social medicine have different basic areas of concern, and there is a tendency on the part of clinicians to distrust anythine which is not clinical medicine. The remedy for this situation is outside the scope of the present paper but it should be clearly recognised that as with the other medical sciences whose methods differ from those of clinical medicine, it is essential that undergraduate courses should at least equip the student with sufficient grasp of methoQ to enable him to appreciate the importance of fundamental contributions within the field. Methodological concerns have been primarily the pre-occupation of statisticians. Since modern statistical theory and method have been developed to a high level of sophistication this is perhaps inevitable. It is uncommon to find a medically trained man with sufficient ~ of statistical •••

....-

WERO/SOC.PREV.MED./5 Page 5 of statistical theory to be able to advance fundamental methodology. However a grasp of what methods need to be developed or devised is rarely possessed by the pure statistician. To some extent this involves a consideration of personnel within the social medicine department rather than a consideration of appropriate research content but in tact the two questions are not entirely distinct. Social medicine needs the recruitment of non-medical personnel as well as medical. The ideal worker in social medicine research would be medically trained, have experience of practical public health, be a gifted mthematician, be a trained sociologist and have long experience in research in medical science generally. Unfortunately such people are rare and as a compromise departments will usually be staffed by several individuals combining perhaps two of' these requirements each and if possible all requirements between them. Since research projects conducted by mny more than two individuals rarely seem to produce great success a consultative rather than a co-operative employment of individual skills is more usual. Methodological advances have frequently been achieved in this way. A particular problem my be seen to require the development of a particular method. A colleague is consulted and a method developed. The separ.te methodological and other contributions stemming from this co-operation are separately published. Vlhether this is an entirely satisfactory proceeding is disputable. Probably for some time, until workers arise with all the appropriate social medical skillS, it is inevitable. Aetiological research in social medicine has developed directly from epidemiology and in fact represents more a widening of the interest of epidemiology to embrace all disease, noncommunicable as well as communicable, than a new departure. This widening of' interest is not new; it represents a reversion of' epidemiology to the more general preoccupation with the whole field of hunnn health which it displayed before the discovery of microorganisms narrowed its interests. Problems which have engaged attention in these fields have been diverse and all have been concerned with the definition of social categories in relation to the prevalence of diseases. These categories are those which refer tOI 1. 2. Variations in response to pathogenic stimuli found between different individuals; Variations in social eavironment between groups whether resuJ.ting from group characteristics of from external euvirooments associated with groups; and kind of exposure to pathogenic agencies. Variation in response to pathogenic (or other) stimuli between different individuals is so old and accepted an observation in medicine that for centuries little or no attempt was mde to explore its origins. No doubt the preoccupation of clinicians with individuals and the lack of suitable means of' examining groups also contributed to the failure of medicine to investigate one of its more striking phenomena. The investigation of human variation falls naturally into the domin of social medicine since inter~sO!t).l variation is not of course even evident until the group is examined, wch less can it be understood. Intra-personal variation tends •••

3. Variations between different social groups in extent, degree

WPRO/SOC.PREV.MED./5 PaBe 6 variation tends also to have en~ed the attention of workers in social medicine largely probably because it is most conveniently investi~ted by techni~ues similar to those ~loyed with respect to inter-personal observations. Current theory attributes human variation partly to variations in the distribution of human genes and partly to differences in experience between individuals from the time of conception. The intellectual rewards from the study of e;enetics together with its central importance in the understanding of human variation have combined to promote an intensive development of this branch of social medicine. Clues are increasingly becoming available to the complexities of the interactions of heredity and environmental in determinine; physiological and pathological variation. Human genetics has enlarged its scope from a consideration of the transmission of Genes to a consideration of the development of the characters associated with them. It is an i~rtant branch of research in social medicine. The role of environment in determining human variation has long been recognised. Variations in ac~uired immunity according to previous exposure to infection, or variations in body fat according to dietary content are good examples. Evaluation and identification of responsible environmental factors has been facilitated by social medicine en~uiry. A field of growing importance is the study of the pre-natal environment and its effect on maturity and viability. It is difficult to see how this subject could have been greatly advanced without the use of the epidemiological or social medical method. The identification of the social environments in which diseases occur has formed a major part of the social medical effort in aetiolOgical res~ch. Its history extends at least as far back as Hippocrates and it was prosecuted energetically by Budd, Snow and Farr in nineteenth century England. More recently there has been a tendency to distineuish physical or external environmental agencies associated with particular social groups from environmental agencies inherent in the group and to which its members are exposed by virtue of their membership. This latter type of environmental factor has been explored extensively with respect to the aetiology of psychiatric and psychosomatic diseases. Such a distinction is not altogether a clear orehawever. For example it would be difficult to attribute the raised infant mortality rate in later born children of large families confidently to either category of environmental agency. To conduct reserach into the medical importance of the physical environment is of course nothinc new and is merely to continue the traditional field of environmental hyc;iene. The observation that social medicine is not exclusively concerned with environnental sanitation has been taken "lidely to indicate that it has no concern at all with this subject. But such a view is difficult to defend. The need for environmental sanitation arises almost ex~usively from the fact that man lives in social aggre~tes and its provision is dependent on an appropriate level of social organisation. That social medical research departments devote little time to this subject stems more from the fact that many of its problems are already solved (even though the discovery of solutions has not always been followed by appropriate action) than from any consideration that the subject is inappropriate or unimportant to social medicine. Historically, environmental sanitation is ••• r ---'

WPRO/SOC.P.REV.MED./5· Pa.ge 7 sanitation is well worthy of note as being amons the first examples of socially orsanised implementation of recommendations based on social medical knowledge. There is still room for work in this field particularly in tropical countries. Closely related to the identification of social environments associated with prevalence of disease is the similar problem of identifying social sroups characterised by variations in the dxtent and kind of exposure to pathogenic agencies to which they are subject. The question has implications outside the aetiolosical field as well as within it. Its aetiologica.J. importance may be derived from the kind of verifiable hypotheses concerning pathogenesis wich can be constructed from such knowledge or from, the opportunity for direct control of disease Wich such knowledge may afford. Much of the work in thise field has been concerned with occupational hygiene and with the problems arising from risks specific to such special classes as expectant mothers, children or the aged. Descriptive reseazch in social medicine has had wide applications in the investigation of both physiological and pathological processes and ,states. Hwnan srowth, and development have been extensively explored by suitable applications of statistical anthropometry. Clinical medicine owes such to social medical methods applied to the identification and delineation of syndromes. A much neglected field of social medical reserach has been the study of 'What Crew (1944) has called "the social ae;encies 'Which are propitious to maximum health •••• " Study of the sickness needs of society and their variations between identifiable social e;roups should form the basis for a rational desisn of socially provided hea~th care whether in the preventive or therapeutic fields. Few societies make no provision for the health needs of their members but few develop services on the basis of accurate assessment of need. Yet maximal efficiency in the apportionment of the usually limited resources available for health services is vitally important. Almost all research in this field has been done on the North American continent where social prOVision of sickness care is probably least developed among Western nations. Similar research is now bee;inning in England. Of all the soc1a.J. medical research fields this may well be the most important one to develop in Asian countries 'Where needs are relatively e;reat but imprecisely known, . and 'Where available resources are severely restricted. It has been objected that such evaluation of relative needs is invidiOUS, but in areas where resources are insufficient to meet IOOre than a SIl8ll proportion of the need, distinction is inevitably made. It is better that such distinction should be rationally based than randomly. The foregoing attempts to sue;gest a profitable field for research activity in social medic ine. From consideration of its origins and of work already achieved the scope of social medicine has been briefly set out. Future discussion and work may indicate the need for reorientation of thinking about the proper function of this e;rowing field. Some of this discussion will take place during the present seminar and it has been the author's intention not to provide an extensive or authoritative exposition of the proper scope of social medicine but to provoke discussion. Reference to •••

..... WPRO/SOC.PREV.MED./5 Page 8 Reference to specific research projects has been del.iberately omitted, as has any discussion of functional., organisational. and administrative probl.ems invol.ved in the creation of research departments. It is hoped that these questions will be discussed by the seminar i f that is the wish of members.

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila., Philippines

REGIONAL OFFICE FOR THE WESTERN PACIFIC

WPRO/SOC.PREV.MED./6 4 September 1957 ORIGINAL: ENGLISH

16-29 Octobe~ 1957

ORGANIZATION OF DEPARTMENT OF PREVENTIVE AND SOCIAL MEDICINE by Edwrd Ford, M.D. * CONTENTS Page 1

TERMINOLOGY

1 1

THE NECESSITY FOR AN mmPENIENT DEPARTMENT THE FUNCTIONS OF THE DEPARTMENT OF PREVENTIVE MEDICINE AND SOCIAL MEDICINE Teachins Research Advisory and consultative Postgraduate training Student health and welfare service

2 2

3 3 3 3

DEPARTMENTAL PERSONNEL

4 4 4

4.1 4.2 4.3 4.4 4.5

,It

The staffins of undercraduate teachine departments ••• Who1e-time teaching staff Part-time teaching staff Extra-mural services and facilities Research staff

5 5 5

*Professor of Preventive Medicine and Director, School of Public Health and Tropical Medicine, University of Sydney, Sydney, N.S.W., Australia

WPRO/SOC.PREV.MED./6 Pa.cel 1. TERMINOLOGY

The discussion of this subject has been rendered difficult, in recent years, by the varyinG use of terms denoting the broader fields of study. Public health, hYGiene, preventive medicine and social medicine are, in this resard, frequently used as synonyms, and chairs and departments with the same broad functions bear one or other title. This is perhaps of little importance in reGard to the names of well established departments, in the evolution of which newer concepts have Gradually modified their oriGinal roles as sChools of environmental hYGiene and sanitation, and the present function of whiCh is understood, at least within their own faculties. Trouble arises, however, in discussions, such as thiS, with collea(3Ues from other places, though participants are on more or less common Ground. It arises in a more critical way where academic cOmmittees, composed of non-professional and non-public health medical personnel, are concerned with the establishment of new departments, or extension of the functions of ones already existins. For here indefiniteness in the current usage of terms, especially in that of "social medicine," may well lead to misunderstandins and ultimate lack of support. It is not proposed to discuss the subject of terminology here. But it will be taken, as at the Nancy conference, that the terms "hYBiene and social and preventive medicine" will be used to indicate the subjects usually taught under the various titles of public health, preventive medicine, hyciene ands:>cial medicine. With this simplification, we may consider that departments with any of these titles will be concerned to varying degrees with environmental hygiene and sanitation, as well as with preventive and social medicine. 2. THE NECESSITY FOR AN INIlEPENlENT IEPARTMENT

.""

,it

Many members of medical faculties consider that the responsibility of their school, in resard to preventive and social medicine, ceases with the provision of a formal, and often &hort, course of lectures to undergraduate students~ SuCh limited responsibility may be fulfilled by a single parttime lecturer, who may be devoid of any intra-mural faCilities, and may have little contact with other tea.Ching departments. In many British, and most Australian schools, where suCh a condition occurs, the lecturer is usually a well qualified staff member of the health authority, and has the advantage of the use of the facilities of his service for tea chine purposes. SuCh an arraneement may be considered suitable in certain places where health services are well developed, and postgraduate facilities exist for the training of full-time health officers. But i 1: fulfils only part of the functions of a full department, and has Great disadvantages. These would be especially apparent in the case of schools whose graduates, in the absence of trained full-time health officers, will be responsible for public-health duties, in combination with their clinical work, and where community health services are not well developed. Under such circumstances, an adequately staffed department is essential, and as the training centre for the whole of health service personnel, as undergraduates, it assumes a national •••

WPRO/SOC.PREV.MED./6 Page

a national importance. Contrary to the general feelinc of many facul.ties, the greater the degree of underdevelopment of medica~ traininc and local health faCilities, the ~ter is the importance of establishing a ful.l well-staffed department. A full department is also of prime value in the development of the subject within the medical school. For professorial representation on the faculty ensures that the requirements of the subject are pressed at all times, and that, at least, proper consideration is given to developmental proposals. It is only from such a centre that the interests of the widespread and often diffuse subjects of the course can be fostered, adequate facilities obtained, experiment on teachine methods undertaken, and the work correlated with that of other departments and extra-mural bodies. For it is notorious that, in the absence of proper representation, and especially with the current crowding of the medical curriculum, there are few voices raised in favour of the subject. With the establishment of an active department, the wide impact of its work on all other departments can be expected to rapidly raise the status of the subject within the faculty, and to make manifest the importance of its teaching and investigational activities to medical education generally. ,. THE FUNCTIONS OF THE DEPARTMENT OF PREVENTIVE MEDICINE AND

SOCIAL MEDICINE 3.1 Teachi pre~ntive

The prime function of the department is, briefly, to inculcate a and social outlook throuBhout the medical teachine of the facul.ty, and consequently to mould the concepts of the practisine profession in this regard. To this is added, to a degree which depends on local requirements and development, the teaching of technical detail of environmental hygiene and sanitation. The organisation of the large number of varied subjects forming the formal course, and their co-ordination to this end, must be developed with a clear regard to local needs and to the local social and economic backeround. It is also necessary, for the utilization to the greatest advantage of the limited time available, to ensure collaboration with various branches of the health services and other a.gencies. The organisation of trainine, the trial of teaching methods, and the ade1.uate use of extra-mural facilities, such as health centres, health districts, rural centres, student health services, general or croup practices, are amone the most important functions of the department. In the absence of guid.:l.ng departmental direction, the development of adequate methods is haphazard and protracted. The desirable aim of extendinc the teaching of the subject from the usually limited bounds of the formal course provided to its permeation of all clinical subjects, has been mentioned. The indoctrination of clinical teachers, the co-ordination of stUdies with those of other departments and collaboration with these in teaching projects of common interest are all important steps in achieving this object. 3.2 Research

.,.'

WPRO/SOC.PREV.MED./6 Page 3 3.2 Research Resecrch activities form one of the most pertinent justifications for the establishment of an independent teaching department. In addition to enlivening its teaching, the research work of the department may form a valuable adjunct to the official health programme, and be a source of added support and co-operation. Assistance in the related problems of other teaching departments, such as the provision of statistical aid, collaboration in industriaI health problems, and field investigations, are also of importance in extending the influence and usefulness of the department within the Medical School. Access to statistical advice will be necessary in a large part of investigations undertaken, and the availability of a section of statistics, which is able to deal with the problems involved, is of the greatest value. To be completely satisfactory, this should form part of the department. In addition to its value in investig.ational work, the officer in charge of the section will normally assume the teaching responsibilities for the subject of vital statistics in the formal undergraduate course. The provision of a statistical section forms a solid basis for the research work of the department, and can readily develop into a valuable advisory centre for oth.r departments of the faculty, and extend the influence of the school to extra-mural workers and org.anisations requiring advice or guidance.

3.3 Advisory and consultative The provision of advisory and consultative services to other departments of the faculty, and to extra-mural bodies and workers, has been previously mentioned as a valuable means of broadenine the influence and enhancing the usefulness of a department. Work of this nature also provides useful experience for members of the departmental staff.

3.4 Postgraduate traininc Although it is not primarily concerned with formal posteraduate education, a well established undergraduate school may, particularly throueh its investigational programme, provide valuable trainin~ for selected graduates. Experience may be offered in sections of the department in which specialist staff are actively engaged. Statistical, epidemiological and other sections, where available, may in this way furnish experience of particular importance, especially where the facilities of a postgraduate school are lacking. 3.5 Student health and welfare service In some schools the Department of Social and Preventive Medicine is responsible for the conduct of such services; in others they exercise an advisory fUnction in regard to these.

.t.t'

DEPARTMENTAL •••

WPRO/SOC.PREV.MED./6 Page 4 4. DEPARTMENTAL PERSONNEL

4.1 The staffing of undergraduate teaching departments varies widely in different medical schools, from 1ha.t of 1.a.rge 'Well developed departments with the combined responsibility for undergraduate, postgraduate and sometimes certain non-professional traininG, and in which comprehensively staffed sections cover a wide range of subjects, to others at the farther end of the scale, where student teaching 1s covered by a, single part-time lecturer, and where a department, in the usual sense of the term, does not in fact exist. Such great diversity in departmental organisation marks the varying state of development of the teaching of the subject in different p1.a.ces, and depends on many factors. Obvious among these are the general state of medical education and the facilities avai1.a.ble; the degree of emphasis p1.a.ced on preventive and social medicine by the faculty; urgent training needs due to local requirements in regard to such factors as communicable disease control, sanitation, economic and social necessities, development and nature of health services etc.; the degree to which the teaching of the subject permeates the general medical course; departmental research functions; and student numbers. It is not proposed to discuss the staffing of an'.ideal department, or to attempt the important task of definins a suitablEhtaff pattern for the varying conditions that exist in countries throughout the Region; the 1.a.tter, depending on local characteristics and requirements, will form an interesting subject for discussion between Regional representatives. It is perhaps of value, however, to indicate some considerations of' departmental staffing which are mom or less general~y applicable. 4.2 Whol$-1;ime teaching staff The appointment of a full-time medically qualified staff is of prime importance to the stability and developnent of a department, and is a critical action, as far as the future of the subject is concerned. For this reason, every effort should be made to achieve this object, at the outset, in the establishment of new schools; otherwise years are likely to e1.a.pse before a recovery is pOSSible, by difficult re-org,anisation, from the resulting comparatively limping start. The whole-time members, however few, will form a directional centre, and, apart from work in their own specialties, can devote their undivided efforts to the organisation and co-ordination of teaching, corre1.a.tion with other departments and agenCies, and other functions of the department. They give continuity to the studies, and most importantly, especially in the developmental period, act as ever-present spokesmen and advocates for the status and requirements of their subject. The advantages of this 1.a.tter function are enhanced if the staff is headed by a professor, who has full access to the academic bodies, which must usually be indoctrinated and persuaded. For this reason it has been rightly stated that the full exploration of the potentialities of a subject can commence only when its professorial chair is occupied. While the •••

r ..

......

.. ... ,

,..'

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WPRO/SOC.PREV.MED./6 Page 5 While the initial appointment of a single whole-time medically qualified teacher is of great advantage to the department, the desirable minimum may be regarded as a professor and one lecturer. This lays a firm foundation for subsequent development and gives status and full representation to the subject. A lecturer in statistics is a valuable addition to the whole-time staff, both for teaching and especially for investigational work. The many-sided advantages of this appointment have been previously mentioned. ~

In some schools social workers and health nurses are employed as fulltime officers, and are responsible for tea,chine duties and investigational work.

4.3 Part-time teaChing staff The great variety of departmental studies cannot be dealt with satisfactorily by the whole-time staff members alone, and these must be su~le mented by part-time lecturers and demonstrators, who are expert in various social and preventive fields. The teaching duties of each should relate to his own particular field. In general, the part-time staff, drawn from a wide range of health and welfare·activities, provide a most va~uable liaison between their department and the various outside institutions and agencies with which they are ~ofessionally concerned.

4.4 Extra-mural services and facilities A department, for the maintenance of a well developed teaching course, requires close liaison with a multiplicity of outside agencies and services, and ready access for its students to those whose use is desirable in the practical teaching proe:~~l' Thes,e will vn.ry greatly with local development and requirements 1 and -wi~' "t:rre stage of advancement of the course, but in general include the facilities of the public health, industrial health, medical care and social welfare services and agencies. In particular fields of special local importance, as, for instance, training in the technical detail of environmental hygiene and sanitation that is of basic necessity in some countries, special arrangements may be necessary - in the above instance, for example, by the arrangement of co-ordinated work in publichealth laboratories, health of rural centres, and health districts.

4.5, Research staff In some schools research fellows or assistants are employed in investigational projects under the direction of full-time staff members •

.. I

WORLD HEALTH ORGANIZATION STUDY GROUE ON SOCIAL AND mEVENTIVE MEDICINE ManilA, Phillppines

REG IONAL OFFICE FOR THE WESTERN PACIFIC

WPRO/SOC.PREY .YBD./7

27 September 2957 ORIG~:

26-29 October 2957

ENGLISH

m UNIERGRAruATE

THE PIACE OF SOCIAL MEDICINE MEDICAL EOOCATION

by E. S. Monteiro, C.D.E., M.D., F.R.C.P., F.R.F.P.S., D.C.B.* and T. A. IJ.oyd I8v1es, M.D., F.R.C.P.**

TJrl1versity of MUaya, Singapore. ** Professor of Social Medicine and Public Hea.2th, University of MUaya, Singapore.

* Dean of the Fa.cul.ty of Medicine and Professor of Cllnica.2 Medicine,

'. JL.

WPRO/SOC.PREV.MEP./7 Pagel Few persons will agree about the definition of social medicine. Throughout the world, each department of social medicine seems to have its own concept and on the basis of this concept to pursue its own field of study. The one extreme is represented by tra.ditional public health, originating as an extension of bacteriology but now ousted by virology; and the other extreme by the administrative organisation of hospital care. To some, the name social medicine is an anathema suggesting socialised medicine. To counterbalance the spectres of socialisation so wrongly conjured up, may we point out that in 1875, Wil.llam Farr (whose work as first Registrar General mde social medicine possible) suggested medecine conserva.trice from medecine ;beservatrice of Corvisart and Concordet. ~e difficulty of definition, iCh in any case is of little importance to medical students, is resolved if we consider the place of social medicine in medical education.

In considering undergraduate teaching in social medicine, two difficulties arise. First, the field covered by social medicine is so wide that a department of social mediCine, unless of unwieldy size, cannot hope to cover the whole. Secondly, by the nature a:f social medicine, principles and techniques must be borrowed from other branches of medicine. In some ways, this is an advantage, allowing close association with whatever branch of medicine is of special interest. A serious disadvantage is that, in considering the overcrowded undergraduate teaching 'programme, what principles are to be taught by departments of social medicine? With the present pressures on medical students' time, depu-tments 'Which do not have principles to teach cannot expect to be allocated more than a nominal number of hours. We suggest that the prinCiple of relationship is the justification for the inclusion of social 'medicine in the undergraduate curriculum. No mn can be uninfluenced by his heredity or live outside the culture in 'Which he has been nurtured, or remain unaffected by his environment. Most of all, a man is ai'i'ected by his fellows; how the basic hUIlBn needs of being. loved and being lovable are met will decide the meaning of all other influences. The meaning to him will determine his responses. The older textbooks of medicine contained accounts of the natural history of disease, but, as clinical science has become elaborated, these accounts have been omitted. However much we regret this, the primary duty of a clinician is to diagnose and treat disease. Of course, the wider the view of illness taken by a clinician the better, but unless he be a reuarkable man, the time absorbed by the non-clinical duties may place him in danger of diagnosing and treating the patient less well thnn he might. We would like to stress this central function of physician as if any serious attempt is IIBde to fulfill the programme of teaching in social medicine suggested by Grundy and l-Bckintosh (1957) clinical instruction would be crowded out. Until a stUdent is fitted to diagnose and treat he is not fitted to be a physician. For this reason, social medicine must be subordinate to clinical medicine (using the term to cover the 'Whole field of medical, surgical, obstetrical and psychiatric practice). Social medicine ~,however, profitably supplement the efforts of clinicians in considel'l.ng the various and many influences giving rise to disease, and how these 'influences pressing on the patient may be modified to aid his full recovery. A great deal of clAptrap surrounds social medicine. Phrases like 'Whole nan, positive health, total environment, must be eschewed as having little, if' any, precise meaning. Even the meaning of thll word health is •••

WERO/SOC.?REV.MED./7 Page 2 health is disputed. In teaching the principles of relationship we are concerned why that particular ;patient developed that ;particular illness andh:nl that ;particular set of circumstances can be modified.

Ii' this attitude is naintained, social medicine is an applied and practical subject and only as such will it appeal to that very practical mind of a medical student. One unexpected benefit of having to deal in relationship is that students have to think of the significance of facts rather than as they are so fond, indulging in mere reproduction of unrelated scraps of knowl.edge . ' . Ii' this be granted, the fiel.d chosen for speciaJ. study is of littl.e moment provided it is related to probl.ems which will have to be faced by the student when qualified. In Malaya, with scattered rural villages, rural sanitation is important; in HolJ.a.nd, with a very .emcting sociaJ. organisation, mental. heeJ.th is important; and in Great Dritain, which is higb.J,.y industrial.1sed, occupationaJ. heal.th:!At important. These practical needs must in1'J.uence the exampl.es used to illustrate the principl.es of relationship. Departments of social medicine which stray too far from the practical. needs of the countries they serve will rightly neither attract the regard of the student nor achieve a high status in the structure of their medical school.. The real Significance of fiel.ds chosen for study is that staff shoul.d be expert (in their chosen fiel.ds) I so as to attract the respect of clinical colleagues • . No ,ideal method of teaching social. medicine or any other branch of medic.ioe has yet been found.~ Fornal. l.ectures playa limited part nainly introducing the student to basic subjects like statistics and the availability of socio-medical aid. The nain prop of teaching must be the aSSOCiation with clinicians at the bedside. For thiS, students shoul.d be required to add to their medical cl.erking such investigations of the patient's circumstances as are related to illness. This nay incl.ude a dietary investigation, separati.on of hooklrorm larvae from the soll of a farm, visit to the place of work; discussion with superintendents of Homes for the blind, d;eaf or indigent, but· shcul.dalways include at least two visits to the patient's home. Thfi 'student must 22,.,e.verythingthat is done for the patient. Advice and . guiQance shoul.d befreel.y available to the student, but supervision shoul.d be reduced to a miniIrnlm (we find, as in the United States of America, that the stlldent feels his responsibility so acutel.y that he is most unlikel.y to .make rash mistalles). Students l.ike doing things and this alive apprcach is in direct contrast to the dull elaborate case hLstories to which nany social workers are addicted and which have nade social medicine unattractive to medical students in Dritain. Quite often, students are shocked by what they see but, at the very least, will not now be tempted to offer their patients impracticab1& advice. De cause ·the family is the basis of SOciety, where standards of decent and delicate behaviour are l.earnt, where the micro-environment can be so disastrously distrubed in favour of disease, where love of one human being for another can be so beneficiall.y given or so disastrousl.y withheld, special. study is needed. Whether this is through a short apprenticeship with sel.ected general. practitioners, as in Manchester, or through family care schemes being devel.oped in the United States of America, or through a public-health sw:vey as in Singapore, natters llttle. The important thing is that ••• ".

....

WPRO/SOC.PREV.MED./7 :page 3 is that students should enter homes and establish an intimate professional relationship. Only in this way can they lea.rn of the profoundly beneficial result of one human being being kind to another. M:\.ybe for the first time" they will be introduced to the priestly function of physicians. One warning is necessary. Horrified at the lives of their patients, some students undergo a deep emotional disturbance. This is a process which all physiCians must face, sooner or later and in our view does no harm i f wisely handled by the teacher. In undergraduate teaching, the engineering and technical aspects of water supply, sanitation and similar subjects need scarcely be mentionea. Principles may be expounded but what is important is how the provision or lack of public-health services affects the lives of his patients, and disease is spread. A short account of medical economics, as it affects the countries in 'Which the student will practise, is permissible, but elaborate instruction in the administration of medical care is out of place. Enthusiasts for integrated teaching progra.ImDes, especially in North America, base their enthusiasm on the grounds that pre-clinical and clinical disciplinary studies reduce a student's attitude to patients to the unhumanistic diagnosis of disease. In short, they claim patients become cases. Of course, this can happen, but only i f such attitudes are displayed by clinical teachers. In parenthesiS, we may remark that to the student clinical teachers are all important. Social medicine does not have the function of taking upon itself' to correct the deficiencies of-other subjects. It can, however, supplement cllnic.1.ans' efforts to relate all causative factors to the patient and his illness, to understand the patient's customs and response, and to employ all available aid in the management of the patient. If at the end of his course a student has learnt the importance of relationships, and that, 'Whether amid squalor or luxury, misery or joy, the oQJ.y true relationship between hu.ma.n beings is love, then teachers of social medicine may rest content. In the simpliest societies, the phYSician has to do little more than relieve suffering. As societies become more complex, so the medical procedures must be interwoven with services provided by the state. The danger, of course, is that medicine is itself' reduced to a social service. In South East As:la, we stand somewhere between the simplest and most complex societies. The speed of transition seems to be quickening so traditional patterns of living are being upset aJ.most every day. If the practitioner is to understand the a..lmcBt infinite combinations of causes which affect his patients, the student must be given a chance of watching men work out their purpose and destiny. Men do not do this in hospi tale but in their homes, their work, their play and their dying and to give the student th1s experience of living is the ultimate justification of social medicine. References GRUNDY, F. & MACKlNTOSH, J.M. The T. aching of Hygiene and Public Health in Europe.

Organization, Geneva, 1957, Monograph Series No.

34.

World Health

'f&.

WORLD HZALTH ORGANIZATION STUDY GROUP ON SOC IAL AND PREVENTIVE MEDICINE

REGIONAL OFFICE FOR THE WESTF.RN PACIF'IC vlffiO/SOC .PREV.MEn ./8 ,

16 September 1957 ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957

TEACHING OF SOCIAL .AND PREVENTIVE MEDICrnE FOR UNDERGRADUATE MEDICAL STUDENTS IN THE REPUBLIC OF KOREA

by Chao Wan Myung, M.D.* and Sang Whang Shim, }:!.D. *,k

CONTENTS Page

1 2

INTRODUCTION THE MEDICAL TF..ACHING ll!STITUTION THE FACULTY l-lEMBERS OF PREV:illTIVE NEDICTIlE CURB.ICULUM OF PREVENTIVE MEDICINE REIA TIONSHIP BE'IWEEN PREVENTIVE MEDIClllE AND OTHER FIELDS PUBLIC HEALTH COURSE III GENF.uttAL COLLEGE PROFFSSIONAL ASSOCIATION CONCLUSIONS

1 1

3 4

1 2 2

,--

6 7

3 3 3

, ill.

* Dean, College of Medicine, Seoul National University, Seoul, Korea

-** Professor of Preventive Medicine, College of Medicine, Seoul National University, Seoul, Korea

•

WPRO/SOC .PREV .HEn./S Page I 1.

INTRODUCTION

Until the end of World War II, Korea was under Japanese control, and most of the educational systems were based on Japanese and German ways. At the medical schools, course of IIHygiene ll was given to undergraduate students. In this course, students were taught no more than environmental sanitation and some parts of physiological hygiene. At the outset of World War II, under the auspices of the Allied Armed Forces, the concept of public health was rapidly introduced into this country. The former idea on hygiene has gradually been changed and developed to that on modern social and preventive medicine. 2. THE MEDICAL TEACHING INSTITUTION

l-Jhen Korea was divided into two parts following World War II, there were five medical schools in South Korea. Three medical'schools were established newly in addition to these schools •. Among eight medical schools, one is for women students only. F~ch school has the Department of Preventive Medicine or Department of Hygiene. Although some concepts on social medicine are taught to undergraduate medical students, there is not any Department of Social Medicine nor Department of Social and Preventive Medicine. 3.

THE FACULTY MEl'1BERS OF PREVENTIVE HEDICINE

Although there were few persons qualified in this field before the liberation of this country, many persons, thereafter, have studied or are studying abroad. Each Department of Preventive Hedicine or Department of HYgiene is staffed with a few personnel, the number of personnel varying from two to aight, according to the size of the institute. Host of them were trained in the United States of America, and the concept and system of preventive medicine and public health in the U.S.A. have been introduced and taught to the undergraduate students. Under the present specific conditions in Korea, it is quite necessary to have the idea o~ social medicine more strongly for every faculty member. Anybody must be considered not only as a complete individual, but also as a component part of his social environment. This principle must be understood by students who will be physicians in the future. Therefore, one of the most urgent task in teaching this principle is that faculty members themselves should recognize and understand this principle completely. They should have complete understanding of the society served as composed of individuals and groups whose health and disease problems are affected by the physical, psychological and social environment within which they live. Much attention must be paid to this point in Korea, because some of the faculty members would not care for this principle on social medicine. 4. CURRICULUM OF

...

WPRO/SOC.PREV.r1ED./8 Page 2

4. CURRICULUM OF PREVENTIVE HEDICINE At most of tha medical schools in Korea, the following subjects are usually given for undergraduate medical students: For Sophomores: 1) Environmental Sanitation 2) Racial Hygiene 3) Medical Statistics 1) Communicable Disease Control 2) Industrial Hygiene 3) Epidemiology 1) Public Health Administration and Practice

For Juniors:

For Seniors:

The amount of time is relatively well allocated in relation to the general time-sequence of the medical course. Compared with that in the U.S.A. more hours are allocated for this field in this country. The relative homogenity is considered to some extent in this country. Laboratory works are also rc~uired for undergraduate students. These involve visits for observation. The main subjects of the laboratory works are water examination, study of air and sewerage, food and milk sanitation and so on. Praotice of biostatistics is also given. At certain schools, schedules on home visiting and health centre activities are carried out. 5. RELATIONSHIP BET\vSEN" PREVENTIVE MEDICINE AND OTH:<:R FIELDS

Usually the individual departments are so busily engaged "I-1i th their specific jobs of service, teaching and research that it is di~ficult sometimes to expect them to give primary attention to the integration of their fields of endeavour with others. This is especially true in this country because of the lack of general recognition of the fact that no aspect of medical care is independent of any other aspect. It is important to know that the Department of Preventive Medicine is in a position to facilitate the integration of the activities of other clinical departments in the interest of complete care for the patient and consideration of the total circumstances of his illness. As of now, however, this is rarely carried out in this country. To fulfil this purpos e, as vlHO suggested through the Expert Committee on Professional and Technical Education of Medical and Auxiliary Personnel, the Department of Preventive Medicine must use the community as a laboratory for the study of health and illness phenomena under the same rigid standards that apply to the study of those aspects of disease which must be observed in the science laboratory and the hospital ward. At certain medical schools in Korea attention is paid to this point and some good plans are carried out. Furthermore, in the work of the Department of Preventive Medicine, close co-ordination with the community health agency is mutually advantageous and strongly desirable. Although

, there are only •••

WPRO/SOC.PREV.MED./8

Page 3 there are only a few schools whose Departments of Preventive Medicine are in close relation to the community health agencies, this work should be applied to all medical students in this country in the near future.

PUBLIC W.ALTH COURSE IN GENERAL COLLEGE

At certain universities in this country a public-health course is required of the entire freshmen as a course in general college to improve their thoughts on health. Most of the colleges and universities are attempting to carry out this course as soon as possible. According to the lack of recognition on public health concepts, there will be found same difficulties on the way to achieve this course. It is, however, quite needed to have this course because of the urgent necessity of this kind of knowledge not only for the school administrators or students but also far the general population. As of now, some student health services are functioning in certain universities. The Department of Preventive Medicine is partiCipating in the students' health control activities through these agencies. Owing to the good results, many other schools will be expected to have such agencies. The concept on student health services is relatively a new one in this country. But every person will recognize its value in the very near future. 7. PROFESSIONAL ASSOCIA TION

The Korean Academy of Hygiene has been organized under the Korean Medical Association several years ago. This Academy is composed mainly of the staff of each Department of Preventive Medicine or Department of Hygiene. The st.ff can communicate with each other regularly and freely through this organization. This Academy has recently published textbooks on preventive medicine for undergraduate medical students which are used by all eight medical schools. In addition to this organization, the Korean Public Health Association is expected to be born on September 20th. 8. CONCLUSIONS

The present situations in Korea are described briefly and to improve the better education for undergraduate medical stUdents, the following are desired: 1) The Department of Preventive Medicine must be staffed and equipped adequately, and co-ordinate its efforts with all the departments of the school, both basic and applied. 2) International collaboration is needed. The experiences and knowledge should be exchanged in the interest of health of general population on the world.

WCIW) HEALTH

ORGANIZATION

BEG IONAL OFFICE FOR THE WESTERN PACD'IC WPRO/SOC.PREV.MED./9 20 September 1957 ORIGINAL: ENGLISH

AND PREVENTM

STUDY GROUP ON SOCIAL MEDICINE

Manila, Philippines 16-29 October 1957

FOR

~GRAIlUATE

'lEACHING OF SOCIAL AND PREVENTIVE MEDICINE MEDICAL eTUlENTS m THE PHILIPPINES by Manuel Ma. Aycardo, A.n., M.D., C.P.H.,* Hilario tara, M.D., M.P.H., Dr.P.H.,** Virgilio Ramos, A.n., M.D.,*** and Agerico D.M. Sison, A.D., M.D.****

CONTENTS

1 2

DACKl}ROUND INFORMATION NUMDER AND OWNERSHIP OF MEDICAL SCHOOLS

1 1 2 2

ENTRANCE ~UlREMENTS AN.I.- LENGTH OF MEDICAL COURSE ENROLIME:NT 'lEACHING OF PREVENTIVE AND SOCIAL MEDICINE

4 5

*Associate Professor in Charge of Preventive Medicine, university of Sto. Tomas College of Medicine and Surgery. **Professor and Head, Department of Hygiene and Preventive Medicine and Dean, Institute of Hygiene, university of the Philippines College of Medicine. ***Dean and Professor of Clinical Surgery, University of Sto. Toms College of Medicine and Surgery. ****Dea.n, Professor and Head of the Department of Medicine, Uni versi ty of the Philippines COllege of Medicine.

WPRO/SOC.PREV.MED ./9 Page 1 1. BACKGROUND nWOWlATION

l The Philippines consists of a ~roup of 7,083 islands ; area 115,600 square miles (major islands: Luzon 40,420 sq. miles, Mindanao 36,537 miles, Samar 5,050 miles, Negros 4,,905 0 miles, Palawan 4,550 miles, Panay 4,440 miles) ly~g between 21 10" and 4 40" ~orth latitude and 126°34" East longitude; 1957 estimated population 22,689,700; literacy 59.8% Philippines and 86.8% 11anila4 ; agricultural economy but gradually indus trializing. The 1950 Hedical Directory gave the ratio of physicians to population as varying widely for 1 to 493 in Manila and 1 to 33,347 in Bohol. The very uneven distribution of physicians has been partly corrected with the implementation (beginning about 2 years ago) of Republic Act 1082 as amended by Republic Act 1891, and supplemented by Republic Act 1136 (Tuberculosis Act), RepUblic Act 1939 (Hospital Act), and Republic Act 997 (General Reorganization Act). 2.

NUMBER AND OWNERSHIP OF MEDICAL SCHOOIS

There are seven medical schools, five of which are located in Manila and two in the Visayas. Only one, the University of the Philippines College of Medicine (founded in 1907 by Act 1415) is State owned and operated; one, the University of Santo Tomas Medical College (founded in 1871) is owned and operated by a religious corporation (Dominican Order CatholiC), and the rest are privately owned and operated: Far Eastern University - opened classes in 1952; Manila Central University - founded in 1947; South Western College - founded in 1947; University of the East founded in 1956; Cebu Institute of Technology - founded in 1957. With the exception of the U.P. College of Hedicine, none of these schools receive government subsidy or support and their expenses for operation and maintenance are derived chiefly from student fees.

3•

ENTRANCE •••

1 JvlcKinley, Earl B. - A Geography of Disease - (A Study }fade Possible ~ a Grant from the American Leprosy Foundation to the Division of Hedical Sciences of the National Research Council, Washington, D.C. U.S .il • ), p. 34

2 World Almanac - 1957 3 Philippine Bureau of the Census 4 Jacobini and Associates - Government Services of the Philippines p. 64; also Statistical Bulletin, 1953, Bureau of Public Schools.

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WPRO/SOC.PREV.MED./9 Page 2 3. ENTRANCE REQUIREMENTS A~m

LENGTH OF MEDICAL COURSE

The admission requirements, except in the College of 11edicine of the University of the Philippines, are completion of at least two years of preparatory course in a College of Liberal Arts and good moral character. The State-owned U.P. College of Medicine, which sets a rigid enrollment limitation (competitive), requires for admission: (a) completion of at least three years of University preparatory medical course with a high grade; (b) passing a Committee personal interview; and (c) good moral character. The regular medical course covers five years of study, the fifth being one full year of internship in a hospital as required by law. Satisfactory completion of the course leads to the degree of doctor of medicine (M.D.). Before a medical graduate is allowed to practise medicine in the Philippines, he must pass the examination conducted by the Government Board of Medical Examiners, must be not less than 21 years of age, and be of good moral character. 4. ENROLLMENT

"'"'

The enrollment for the first semester of the academic year 1957-1958 for U.P. and C.I.T. and 1956-1957 for other colleges may be noted on the following table: ENROLLMllIT IN SEVEN MEDICAL SCHOOLS First Semester 1956-1957 U.P. FIRST YEAR Male Female SECO~

Clrx 43

UST

MCU 311 208 103 253 172 81 257 182 75

FEU 946 591 355 420 279 141 309 201 108

$WC

135 101 34 112 75 37 101 81 20

1,195 645 550 1,001 604 397 689 429 260

1947 201 132 69 103 68 35

1956 : TOTALS 170 114 56 1,889 3,001 -;"

YEAR

Male Female THIRD YEAR

Male Female x 1957-1958

41 27 14

1,397

FOURTH YEAR •••

WPRO/SOC.PREV.MED./9 Page 3

U.P. FOURTH Y1?--AR Male Female INTERN Male Female TOT.Ii. L x 1957-1958

crf

UST 795 502 293 631 408 223

11CU 293 228 65 184 137 47

FEU 101 75 26 107

swc 1947 30 25 5 18 14 4

UE 1956

;TOTAIS

1,291

57 15 75 57 18 495 43

1,015

4,311 :1,298

:1,883

393

170

8,593

of the Philippines CIT = Cebu Institute of Technology UST = University of Sto. Tomas HCU = Manila Central University FEU Far Eastern University S'I1C South Western College UE = UniverSity of the East 5. TEACHING OF PREVENTIVE i.ND sec IAL MEDICINE

u.P. = University

......

Preventive and social medicine is taught prinCipally in the hygiene and preventive medicine courses offered by the Philippine Hedical Schools, the areas of coverage and depth varying as the prJscribed curriculum call for and the facilities of the. school (personnel, physical plant, ~cluding eqUipment and other teaching facilities) will permi~. Conformably no two schools teach the subject in exactly the same manner. Nonethel.ess the subject is a required course for the degree of doctor of medicine. The teaching staff for this subject in the great majority of the schools in the Philippines do not enjoy full-time university appointment in the strict sense of the word • For the improvement of teaching of this discipline, it is our considered opinion: (1) That Departments of Preventive and Social Medicine of medical schools should be staffed by a complement of (professionally and personally) qualified faculty members on full-time (in the strict sense of the word) University appointment as in other departments of study of the college, so that there be at least one Professor and Head, one A;sociate Professor, two Assistant Professors, and a number of Instructors, all depending on the size of the enrollment of the college, supplemented furthermore •••.

•

WPRO/SOC.PREV.MED./9 Page 4 furthermore by a number of part-time lecturers and praeceptors following the usual faculty-student ratio in approved medical colleges, if teaching of any required discipline of study is expected to come up to the expectations desired as satisfactory. Such teaching staff should be enabled to do considerable research work in their respective fields of study and extend adequate personal individual attention to their students. The professorial staff and the majority of the instructors and praeceptors should have had adequate post-doctoral graduate training and experience in hygiene and public-health (preventive and social medicine) and should be adequately remunerated. They should, coreover, as much as pOSSible, through a system of fellowship, be given chances to travel from time to time to observe the organization and method of teaching of preventive and social medicine in several schools in the United States, Australia, New Zealand, Japan, Indonesia, Halaya, Siam, other countries in the Far East or Near East as well as in Europe and. South Am3rica in order to broaden better their points of vielv on the subject through close contact with various authorities and observation of the manner this discipline is being made to serve different communities in accordance with their respective resources. The continuous development of the teaching staff could never be overemphasized. (2) That in addition to existing facilities in the immediate premises of the college, thos e of gov3rnment and non-governmcmt entities (such as health department facilities on national, city, provincial and muniCipal levels and those of T.B. SOCiety, Red Cross, as well as other resources) should be utilized as much as practicable for teaching and practice. If and when curricular adjustments and readjustments would make it practicable, raving in mind, h01vever, the general objective of medical education, the students might be given as much opportunity as possible to learn the application of the principles and methods of preventive and social medicine through doing rather than confining the instruction to the methods of lecturos, demonstrations and recitations alone. To carry out the details of such teaching programme as here envisioned, a good deal of mutual understanding and close relationship should subsist between the school authorities and the various organizations concerned, and much planning, organizing and systematic supervision of the programme would be needed. Hence the necessity of an adequate complement of qualified fulltime professorial staff assisted by a goodly number of instructors and auxiliary personnel lvith ample means of transport. (3) Tha t it might be d8sirable to embody some pr OVlSlons in the

••

.lr •

medical law which would prescribe a number of specific criteria for departments of study in medical schools to base operation on such as full-time faculty-student ratio, space-student ratio, equipment-student ratiO, faculty research-teaching time ratio, and other essential factors as might be put in effect to ensure good medical instruction. In this connection it might also be desirable to have the Bureau of Private Schools of the Department of Education sufficiently staffed with medical education experts each in the different disciplines who would be in better posit ion to ~.;

. vIPRO/SOC .PREV .MFll ./9 Page 5

position to appraise conditions of teaching of the disciplines and provide competent guidance for continuous development in line with the progress of science. (4) That there should be close understanding and relations between departments of Preventive and Social Nedicine and other departments of the medical schools in the interest of co-ordination and teaching of this discipline in such a way that the clinical teachings might also be made to touch in a reasonable degree on the promotive, preventive and social aspects of health and disease. Likewise, there should subsist close relationship between Departments of Preventive and Social Medicine and health offices of both private and government organizations so that full co-operation may be established in the interest of instruction, research and direct public service. (5) That there is need for continuous study and planning on the part of authorities directed among others on teaching and research facilities and activities in this discipline (Social and Preventive Medicine) and for that matter in any other discipline if medical education would be expected to keep pace with the advance of science. (6) That there be periodic interdepartmental conferences and consultations among the members of the different departments of study of each college and also intercollegiate conferences of select faculty members from different colleges of the country for interchange of views on the improvement of teaching of social and preventive medicine and other disciplines as well. (7) That there be established better mutual understanding and closer co-operative relationship among professors and teachers of preventive and social medicine of the country in the interest of better teaching of this discipline to medical students~

,JI.,

~'lau.D

HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREv.MED./10 23 September 1957 ORIG INAL: ENGLISH

STUDY GROUP ON' SOCIAL AND PREVENTIVE MEDICINE

Manila, Philippines 16-29 October 1957

COMPLETED QUESTIONNAIRE ON THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE FOR UNlERGRAll1ATE MEDICAL STUlENTS "'f '.

CONTENTS Pages 1 UNIVERSITY OF SYDNEY MEDICAL SCHOOL, AUSTRALIA COI.IJ!XZE OF MEDICINE, NATIONAL TAIWAN UNIVERSITY, CHINA SCHOOL OF MEDICINE, KEIO UNIVERSITY, JAPAN NIHON UNIVERSITY MEDICAL SCHOOL, JAPAN SCHOOL OF MEDICINE, FACULTY OF MEDICINE, UNIVERSITY OF TOKYO, JAPAN COLLEGE OF MEDICINE, SEOUL NATIONAL UNIVERSITY, KOREA COLLEGE OF _DIeINE, UNIVERSI'".L"Y OF THE PHILIPPINES, PHILIPPINES 1-3 4-8 9-11 ]2-15 16-20 21-23 24-33

...

2 3 4 5 6

WPRO/soC.PREV.MED./lO Page 1 UNIVERSITY OF SYmEY MEDICAL SCHOOL

SYmEY, AUSTRALIA 1. ,~

Has the College a specific programme for the training of undergraduate medical students in hygiene/public health/preventive medicine/sociil medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by faculty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year • Yes. ~reventive

•

There is a course of 50 lectUres in public health and mediCine, delivered to the students offtfth year (of a six-year course).

(a) (b)

(c)

(d)

~~~ • i~

~~~ >~~ ~k) (1)

History of preventive and social medicine Environmental hygiene and sanitation Housing and living conditions and the public health. Water supplies, emergency sterilisation methods, purification of small supplies, swimming :pools, water-borne diseases. Excreta dis:posal, with special reference to rural and camp sanitation. Food-borne diseases, food poisoning, hygiene of public eating places. Milk-borne disease, pure milk supplies, pasteurisation. Ventilation, overcrowding, air-borne diseases, control of insect vectors and rodents. Health and welfare services, medical care, etc. WHO and International Health. COlllIlOnwealth Health Department organisation, the comprehensive health scheme: medical benefits, phaI'll8ceutical and hospital benefits, maternity and infant endowment, age,invalid and widows' penSions, tuberculosis control scheme, etc. State Health Services, organisation and responsibilities. Local Health Services and the Medical Officer of Health; voluntary health bodies; social health ,vorkers. Duties and responsibilities of the doctor in regard to national and community health and his place in the field of social welfare (associated with course in Medical Ethics). Child welfare - state and Municipal services; welfare centres, pre-school and school health care; accidents ia the home. Mental hygiene; mentally handicapped children. Problems of old age, including welfare, accommodation, medical care. Problem families; alcoholism, delitlCluency. Occupational hea.lth; local industrial hazards; industrial health service::;. MuTiage guidance; health education. Nutrition. Epidemiology and control of communicable diseases; epidemiological methods; specific preventive measures; national, control schemes; cross infection in hospital; preventive medicine in general practice; preventive medicine in country practice; problems of tropical areas. Public-health aspects of certain diseases: e.g. cardiovascular disease, cancer, rheumatism, diabetes, obeSity, etc. Inheritable defects. (m) Statistics.

WPRO/SOC.P.REV.MED./10 Page 2

(m)

Statistics. Measurements of health, including min causes of mortaUty and morbidity; presentation of statistics; population trends; sampUng problems; standardised death rates; Ufe tables, etc.

Has the College a speciaJ. teaching unit (department; division or section) dealing with these subjects? ••• Yea ••• I f so, what is the total number of professional/technical staff?

Department of Preventive Medicine. The professional. staff is used for postgraduate instruction as well as undergraduate teo.ching. Eight full time and four part time deal with the undergraduate course, as part of their duties.

How mny quaUfied facu1ty members devote their 'Whole time to academic work in these subjects? The staff of the Department of Preventive Medicine devote their whole time to academic work but only part of this is at the undergraduate level. How mny devote between half and all their time to these subjects?

•

4. What field work do the students undertake in the course of their training in public health and preventive medicine? Visits are made to Baby Health Centres, antenatal cUnics and pre-school child centres and time is allotted for visits to places of public-health'and industriaJ.-health interest.

Describe the attention paidto industrial hygiene (occupational health) training. As noted under l(h) a section of the f'orual. course (6 lectures) is devoted to occupational. health.

6. Are there any trained medical-social workers on the staff of the hospita.l.s associated with your College? Yes. Each of the teaching hospi tala bas trained almoners who participate in the training of undergraduates and the Department of Medicine has its own social worker, who provides additional training in conjunction with professoriaJ. teaching units. Do they take part in the teaching of undergraduates?

Do studente •••

WPRO/SOC.PREV.MED./10 Page 3

7. Do students carry out any home visits in the course of their clinical training? Yes. lAlring the course in paediatrics the students nay make home visits and write'social case histories. Home visiting in obstetric cases has practically ceased in recent times as most cases are now delivered in obstetric hospitals.

8. Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. ~

The Department of Preventive Medicine supplies a staff member for the discussions and field work for the course in Social Paediatrics.

9. Do the students get any training in medical statistical methods? _ Some training in sampling procedures during their pre-clinical studies. Vital statistical methods are included in f1:f'th-year course, see l(m). 10. Is there a college (or student) health service for the benefit of undergraduates?

No.

Comments and plans for the future Please make any comments here. If relations with the local medical and health services are not sufficiently described above, please amplify here. Do you consider the health services in your community adequate for the field training of undergraduates in public health and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe the problems connected with recruiting suitable personnel who (With or without further training) might be entrusted with the development of such teaching. Adequate postgraduate training in public health is avsiJ.a.ble at the School of Public Health and Tropical Medicine and since the health services and health laboratories of Australia are in the hands of experts, it is considered that the training aJ: the undergraduate in environmental sanitation is adequate without field visits as after his graduation he will not be called upon to provide such services in his ordinary practice. /my extension of the time avsilable for teaching Social and Preventive Medicine would doubtless be vsluable but the undergraduate curriculum is already overcrowded. Consequently it is felt better that efforts should be continued to inco~ Social and Preventive Medicine more :f'ully into the clinbal courses, rather than to attempt to enlarge the formal course.

•

WPRO/SOC.PREV.MED./IO Page 4 COu.mE OF MEDICINE, NATIONAL TAIWAN UNIVERSITY TAIPEI, TAIWAN, Im'UDLIC OF CHINA 1.

Has the College a specific programme for the training of undergraduate medical .students in hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by faculty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. There are two semesters in an academic year. The first semester begins with the end of September and ends in the middle of January. The second semester begins with the end of February and ends in the middle of June. Each semester lasts for about 18 weeks. The course of preventive medicine and public health starts in the~cond semester of the second pre-clinical year with two hours a week every semester up to the second semester of the second clinical year with the total of 170 hours and 14 credits; two credits for each semester. In addition to 170 hours of lecture, discussion and laboratory work, a four-week field training is required of medical students before their graduation. The plan of the course of preventive medicine and public health for the academic year 1957-58 is presented as follows: Allocation Outline of course of hour Lecturer

1) the second semester of the second pre-clinical year (34 hours; two hours a week, two credits) Introduction to preventive medicine and public health Environmental sanitation, including medical entomology 2) the first semester of the first clinical year (34 hours; two hours a week, two credits) Medical statistics Prevention and control of acute communicable diseases 3)

10 24

faculty member of D.P.M. faculty member of D.P.M.

the second semester of the first clinical year (34 hours; two hours a week, two credits) Social and preventive aspects of various diseases case conference 22 J2

)faculty member of Dept. )of P.M. )faculty member of Clidbal ) Depe.rtments

4. the first •••

WPRO/SOC.P.REV.MED./lO Page

5 Allocation of haUl"

Outline of course 4)

Lecturer

the first semester of the second clinical year (34 hours j two hours a week, two credits) School health and heal.th education Industrial hygiene l>til.ternal. and child health Nutrition Mental health

6 12 6 4

faculty member of faculty member of part-time teacher faculty member of faculty member of of Psychiatry

D.P.M. D.P.M. D.P.M. Dept.

the second semester of the second clinical. year (34 hours; two hours a week, two credits) Public-health administration Control and prevention of chronic communicable diseases Health screening and examination Special seminar

12 l.4

part-time teacher part-time teacher J,&rt-time teacher J,&rt-time teacher

6 2

four weeks field training (during the summer vacation a.1'ter the first cl.inical year j four credits) Field training in preventive medicine at the university hospital

2 wIts

facul.ty member of ~.P.M. and clinical. departments )!p.

Field training in public health at Provincial. Health Training and Demonstration Centre 2 wks

part-time teacher and faculty member of D.P.M.

Has the College a special teaching unit (department, division or section) dealing with these subjects? ••••• If so, 'What is the total. number of professional/technical staff? In the College of Medicine, Natione,l Tai'W8.n University, there are two teaching units dealing with these subjects, the Department of

Preventive Medicine and the Institute of Public Health. Originally the former dea.ls with undergraduate teaching and the latter with postgraduate teaching. But due to shortage of teaching personnel, the two units get together to teach both undergraduate and postgraduate stUdents. The total number of professional staff members including part-time staff in these two units are eighteen.

How IlBny •••

WPRO/SOC.PFJ!N .MEn./lO

Page 6

How nnny qualified faculty members devote the;Lr 'whole time to academic work in these subjects? Thirteen. How nnny devote between half and all their time to these subjects? Five.

4. What field work do the students undertake in the course of their training in public health and preventive medicine? As mentioned above ~ medical students should spend :four weeks in field practice of which two weeks are for practice in preventive medicine at the University Hospital, another two weeks for practice in public health at the Provincial Health Training and Demonstration Centre. In addition to the four-week field practice, several field trips to various agencies and facilities related to public health are scheduled. a) Visits of observation ~e followiDG places are vieited under the guidance of their instructor on weekends, immediately after the corresponding subject matter has been covered in class:

1) Visit to water supply plant, sanitary well, sanitary latrine 2) 3)

4) 5) 6)

and restaurants. Visit to industrial factories, such as cigarette and textile factories, and coal mine. Visit to tuberculosis sanitorium, leprosarium, mental hospital and isolation hospital. Visit to priIrBry and secondary schools, and a special school for blind and deaf-mute children. Visit to orphanage, nursery home and official social welfare services. Visit to various health agenCies, such as municipal health center and station, county health center and station, venereal disease clinic and tuberculosis control clinic.

Participation in community health activities Medical students are assigned to participate in community health activities at the Provincial Health Demonstration and Training Centre for two weeks during the summer vacation of the first clinical year. They work together with a team of health workers, such as medical doctor, sanitarian, and public-health nurse in home, school, community and clinic. They can get an idea of what practical public-health work is and how important a role a practising physiCian can play in public health as a resuit of this experience. 5. Describe the ••

WPRO/SOC.PREV.MED./IO Page 7

Describe the attention paid to industrial hygiene (occupational health) training. Taiwan is not so industrialized as other civilized countries so we do not put much emphasis on industrial hygiene. nut we give medical students six hours of lecture on the principles of industrial hygiene and two field trips to some typical factories to understand the needs of industrial workers and of special industrial environments. In field training each student would 'be assigned to work at the health service in a certain factory for two or three days.

6. Are there any trained medical-social workers on the staff of the hospitals associated with your College? In the Division of Social Service of the University Hospital, there are five. college-graduate staff members, of whom two have educational' qualifications for social work and two years' experience in medical social work. Do they take part in the teaching of undergraduates?

No.

Do students carry out any home visits in the course of their clinical.

training? In the field training of preventive medicine at the University Hospital, every student has to make a visit alone or with a public-health nurse in the hopsital to study social and family backgrounds of referred cases; i. e., prenature baby 1 cancer case, tuberculosis patient, cardiovascular case, problem children, psychosis, etc. In the field training of public health at the Provincial Health Training Centre every student should go on home visits with the public-health nurse to learn th e functions of generalized publichealth nursing and the role of the family as a unit of the conununity in public-health practice.

Describe any co-ordinated teaching in curative and preventive aspects in medicine, surgery, ophthaJ mology, obstetrics, paediatrics, etc. In the University Hospital, there are IJll.ny special clinics besides the general out-patient division, such as ' pr&natal and postnatal cliniC, and fertility clinic in the Department of Gynaecology and Obstetrics; well-baby clinic, tuberculosis, cardiovascular and poliomyelitis clinics in the Department of Paediatrics; metabolic, respiratory, cardiovascular, endocrine, gastro-intestinal clinics in the Department of Medicine; trachom and refraction clinics in the Department of OphthaJmology and child guidance clinic in the Department of Psychiatry. Faculty members •••

'.'

WPRO/SOC.PREV.MED~/lO

Page 8

Faculty members in charge of these clinics would give medical students two hours of lecture and one hour of case conference on social and preventive aspects of each topic and would refer a typical case to each student for further investigation of various factors influencing the cause and process of the disease by the method of interview with the patients or their family in the ward, the out-patient clinic and at their home in collaboration with the Division of Public-Health Nursing of the Hospital and the Department of Preventive l~dicine.

10.

Do the students get any trainine; in medical statistical methods? In the first semester of the second pre-clinical year, medical students have eight hours of lecture on medical statistical methods and general concepts of vital statistics and twelve hours of laboratory work on these subjects. Is there a college (or student) health service for the benefit of undergradta tes? There is a health service in the Department of Medicine of the University Hospital. All the students of the College of Medicine can get free health consultation atihis health service. A mass chest miniature X-ray examination is carried out once a year. Two student clinics are located in different campus for students of other colleges. Doctors in charge of these clinics are sent by the University Hospital.

Comments and plans for the future Please make any comments here. If relations with the local medical and health services are not suffiCiently described above, please amplify here. Do you consider the health services in your community adequate for the field training of undergraduates in public health and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe the problems connected with recruiting suitable personnel who (with or without further training) might be entrusted with the development of such teaching. Concerning a four-week field training of undergraduates in public health and preventive medicine; we have changed the schedule several times to see which way may best motivate medical students to be public-health minded in clinical ~ctice after their graduation. During these past three years, we sent medical students back to their hometown to work in a local health station for four weeks, investigating health problems of' the community and understanding what public-health work means. They were quite impressed by this experience. But due to inadequacy of facilities in health stations as a training field and difficulties of close contact of students with the fnculty member during the period of field training, we decided to change it again for the field training for the academic year of 1957-1958 as described in the first item in order to achieve the objectives of field training in both preventive medicine and public health •

WPRO/SOC.PREV.MED./l0 Page 9

SC;-rOOL OF i>iEDIC:LlE, t,EIO UNIVLRSITY TOKYO, JAPAN

Has.the C911ege a.specific programme for the training of undergraduate ill hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic ~ear 1957-58. Please specify the teaching done oy facult;y members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. med~cal students

Yes.

The teaching arrangements for the year 1957-58 are as follows: Subjects Teaching Staff A visiting professor An instructor Hours of Instruction 16 hrs. 34 II

Student Class First year First year & Second year Second year

l'Iedical Statistics Environmental physiology and hygiene Nutritional problems of the people and food sanitation Laboratory work in environmental physiology ane sanitation Epidemiology and vital statistics Industrial health Field trips Public health administration related to practice of medicine and medical care problems

An assistant profes- 18 sor Staff 47

Second year

A visiting professor, 27 an assistant professor and an instructor A professor and an instructor Staff 30

Second year

Third year Second year

& Third year

30 II Third year A professor, an assistant professor (in seminars) Q two instructors Total •.•.

241 hrs.

Has the College a special teaching unit (department, division or section) dealing "ith these subjects? Yes. If so, what is the total number of professional/technical staff?

Department of Pr8ventive Hedicine and Public Health deals "ith those subjects mentioned in section 2. . Professional and ••••

WPRO/SOC.PREV.MED./10 Page 10 Professional am. technical staff: 2 professors, 1 visitin p , professor, 2 assistant professors, 2 instructors, 5 assistants, 5 technical assistants. Total: 17.

Haw many qualified faculty members devote their whole time to academic work in these subjects?

Ten whole-time members. How many devote between half and all their tL~e

to these subjects?

One faculty member is on the half-time and ten are on the l-lhole-time.

~ihat

field work do the students undertake in the course of their training ill public health 2.nd preventive medicine? (a) visits of observation Wa ter purification and Sel-laf;e disposal plants, a milk-products manufacturing factory, National Institute of Health, a lepra sanatorium, Division of Vital Statistics, Ministry of Health and Welfare, and several industrial installations. (b) taking part in community health activities No. Th'e reason is to avoid duplication of instruction which is to be given during the period of internship.

Describe the attention paid to industrial h;'jgiene (occupa tional health) training. Nuch attention is paid by the Department to instruction of industrial health, as seen in the time devoted to this field in sections 1 and 4.

Are there any trained meuical-social workers on the staff of the hospitals associated lvith your College? None. Do they take part in the teaching of undergraduates?

7. Do students carry out any home visits training? No.

the course of their clinical

8. J8scribe any ••• PO'

WPRo/SOC .PREV .MED./l0 Page 11

')cscribe any co-ordinated teach~, in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. Co-ordinated baching is Given ,-lith the medical dopartment on sllch occasions as an;)' patients of occupational disease are admitted to the hospital.

Do the students get any training in medical statistical methods? Yes. See section 1.

10.

Is there a college (or student) health service for the benefit of undergraduates? Yes.

Comments and plans for the future Please make any comraents here. If relations with the local medical and health. services are not sufficiently described abov8, please amplify here. Do you consider the health services in your conununity adequate for the field training of undergraduates in public health and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe tho problems connected with recruiting suitable personnel who (with or uithout furtber training) might be entrusted 'lith the development of such teaching.

WPRO/SOC.PREV.MED./IO

Page 12 NnrON UNIVERSITY MEDICAL SCHOOL (NnrON VMS)

TOKYO, JAPAN 1. Has the College a specific programme for the training of under uate medical 6tudent~ in hygiene/public health/preventive medicine soc 1 medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by faculty members and other persotls, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. Yes, Nihon UMS has such a specific schedule to train the undergraduate medical students in social and preven~ive medicine for the academic year 1957-58, as mentioned below: Curriculum for Soc:i.a.l cnd Preventive Medicine (1957 - 1958) ?ubject Orientation Vital Statistics Population and Eugenics Sanitation Nutrition Food Control Epidemiolo€;y Child Health, including School Health Industrial Hygiene P.H. Administration Health Center Work P.H. Aspects in CPC Comment: Year 1 1 Be 2 2 2 2 2 2 &, ) )

Hours

Instructor Nobechi, Prof.P.H.(t) Okubo, Ass.Prof.P.H~(f) Okubo. OikB.wa, Prof. Hyg • ~ f) Itoh, Prof.Bioch. p) Shiraishi, Ass.Prof.Hyg.(f) Nobechi. Okubo. Nishikawa, Lecturer (p) Mizuno, Lecturer(p) Watanabe, M.D.,Dr.M.Sc. Ckada,M.D.,Dr.M.Sc. ':l:.:;:.oobita,M.D. ,Dr.M.Sc. Nobechi

4 16 64 12

14 60

4 4 4 3 &,

32 32 12 lW 4 Occas.

l' - full-time, Dr. Watanabe

Dr. Okada Dr. Ya.rrashi ta

p -

part-time Director, Chuo Health Center Director, Nihon-bashi Health Center Director, Yotsuya Health Center

."-1t

While Dr. Nobechi was teaching in Nagoya University Medical School (Nagoya VMS), he conducted seminars regarding the reports on the case work as to the individual patients, done by each student from the view point of preventive medicine, in the place of his participating in CPC in Ninon VMS. Aulin the latter he had adopted the Joint Clinic Method before, instead of taking part in CPC nowadays. 2. Has the College a special teaching unit (department, division or section) dealing with these subjects? If so, what is the total number of professional/technical staff? Yes, Nihon UMS has two special departments for the purpose to deal with the work mentioned above. The names of them and the number of their staff members are mentioned below:

....

Department of •••

WPRO/SOC.PREV.MED./10 Page 13 Department of Public Health Professional staff Technical staff Department of HYLiene Professional staff Technical staff 3.

3 5 3 7

How lIBny qualified faculty members devote their whol.e time to academic work in these subjects? The qualified faculty members (Evoting their whole time to the academic work in these subjects are as follows: Department of Public Health Department of Hygiene

How lIBny devote between half and all their time to these subjects? There are none who are devoting between half and all their time to these subjects, among the staff members of the two departments, a.lthough each of the two depe.rtmen1s has one part-time lecturer.

~t field work do the students undertake in the course of their training

in public health and preventive medicine? a) Visits of observation: Division of Statistics, Ministry of Health a.nd Welfare, Water Works and Sewerage Treatment plants, Port Quarantine Station, National Institute of Health, Infectious Disease Hospital, Tuberculosis Research Institute, etc. b) Field work for one week assigned for each stucEat in the following three health centers: Chuo (Central) Health Center, Nihon-bashi Health Center, Yotsuya. Health Center.

Describe the attention paid to industrial hygiene (occupational health) training. Thirty-two hours are a.ssigned to the industrial hygiene.

6. Are there

'0'

WPRO/SOC.PREV.MED./lO Page 14

6. Are there any trained

medica~-socia~

workers on the staff of the

hospita~

associated with your College? To our regret, it has not yet been realized the programme to have trained medical social. worker in the hospital of Nihon UM:l, although in Nagoya OMS, Dr. Nobechi had succeeded upon his appointment to s t aft the school hospital with medi~ social workers, who co-operated in case work by students and in conducting seminars thereof.

.t. ,.,

7· Do students carry out any home visits in the course of their clinical training? No, they do not in Nihon UM:l, although they did home visits as well as visits to factories, schools, health or weli'a.re agencies concerned, in their case work in Nagoya UMB.

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. In order to realize co-ordinated teaching in curative and preventive medicine, the joint clinics method had been adopted in the past, but since CPe was begun, Dr. Nobechi took up the method to participate himsel:t' in the CPC. In Nagoya UMS, he practised the method to conduct seminars on the case work reports as to individual patients prepared by the students, for the same purpose. Do the students get any training in medical statistical methods?

Yes, more than two thirds of the 30 hours assigned to vi tal statistics are spent by the students in actual exercise in medical lltatistical methods. Moreover, in the courses of M:Lternity, Ch~ and School Hea1th a~o statistical exercise is practised by the students under Dr. Okubo. 10. Is there a college (or stUdent) hea1th service for the benefit of undergraduates? The programme of student hea1th service has not yet been realized.

Comments and~ns for the future Pieasee any comments here. I f relations with the local medical. and health services are not sufficiently described above, please amplify here. Do you consider the health services in your community adequate for the field training of undergraduates in public heal.th and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe the problems connected with recruiting suitable personnel who (With or without further training) might be entrusted with the development of such teaching. The Department •••

WPRO/SOC.PREV.MED./lO Page 15

The Department of Hospital Administration has newly been established and is under development in close co-operation with the Department of Public Health. And it has been contemplated to assign the students in some adequate activities of the former to further the co-ordinated teaching of curative and preventive medicines. As to the adequacy of the community health agencies which we are utilising for training the students, we can say they are quite all right, because we selected three most suitable health centers under the qualified directors as mentioned above, out of more than forty in Tokyo.

••

WPRO/SOC.PREV.MED./10

Page 16 SCHOOL OF MEDICINE, FACULTY OF MEDICrnE UNIVERSITY OF TOKYO TOKYO, JAPAN

4th Year I

Total

Hygiene Lecture Laboratory and Visit Public Health Lecture Laboratory, visit and se.1nar Health Insurance Lecture Seminar Statistics Lecture

15 45

30 hours

45. 5 15 20 7.5 22.5 12

47,·5

7.5

30 12

15 ~ -,-,,,

15 .......... ".

.. ..

•

' y-_

NOTE:

104.5 hours Laboratory 21 Visit 33 Seminar 24 Hygiene and Public Health are read by professional staff of the Departments. Health Insurance by a staff of the Ministry of Health and Welfare. Statistics by a staff of the Meteorological centre. c-

Pre-clinical year 75 hours - 41.1,%

Clinical year

107.5 hours - 58.9'% Lecture .. _. __ ). - __.--.",'"\

TOTAL

182.~ hours $.4

.'-

Clinical diagnostics begins here

NAME OF

.. NAME OF UNIVERSITY: .---.-.,,'~---

... of

, 1\

.. t

School of Medicine, Faculty of'Medicine University of Tokyo

Pre-clinical year ~~

. -.-,,-

.'-_._- •..

"-''''-''''''''''''-''

~.,

... ~ ..

..-.. ... _--..

.-,-~

........

i -.--. --- -----. ~.1ST YEAR ....

2ND YEAR

-...

-..

... ...... "

Cl1nica.l year ,

--,-.~~.~

3RD

4 Semi

4TH

YEAR ,

...- . .......

,.--~

.g -+> t)

.r! •

r-I

~l,

t I

l (The coursl closes.)

Principle epi~miolo Desinfecti and disease prevent 'n Rodent and ,nsect contro administra Public-he tion Urban heal Rural heal: Public nui Industrial

continued

~ ~ C\J Vl

Medica.l sot1al work Pbpulationiproblem

'--- '---

Orientation for HYsiene and Public Health

I I

+----..---+----. Occupational disease Seminar ani Lab practice

~ ..........

· ~ · I o· g

-5

Drief aspect of nation'sl health ~ , EnvironmentfL hygiene

..........

~ ~ ~

<11

J.t

= heal!" _,...

(Group studt on specific problems) .

of epide-

I I I ,

V.D. T.D.

---.....----....

{ -~

...

! --_._----..........-t'

.~-

----".;

WPRO/SOC.PREV.MED./10 Page 18

Has the College a special teaching unit (department, division or section) dealing with these subjects? ••••• If so, what is the total number of professbnal/technical staff? No. of professional staff Department of' Hygiene 5 Department of' Public Health 5 The Department of Public Health Practice, School of Health Care and Nursing, Faculty of Medidne, is closely affiliated both in teaching and research of the subject.

_.i

3. How !!Rny qualif'ied faculty members devote their whole time to academic work in these subjects? Ten persons. How many devote between half and all their time to these subjects? Part-time lecturer Research fellows 1

4. 'What field work do the stduents undertake in the course of their training in public health and preventive medicine? a) Visits of' observation Institutions and plants for health engineering. Research and educational institutions resa,rding health. Industries. Primary school and school for the handicapped. Health departments and health centres. Quarantine office, etc. b) Taking part in community health activities Not as curricular but as extra-curricular activities. (see comment (1) below)

, '"

Describe the attention paid to industrial hygiene (?ccupo.tional health) training. The Department of' Public Health, School of MediCine, Faculty of Medicine has been taking special interest in oa::upational health in terms of teaching as well as research activities. The preventive control of occupational diseases and accidents is taken as one of the most important subjects in teaching and research of the Department. Time assigned for occupational health in the course of Hygiene and Public Health i . as follows: Ocrupational •••

, ....

WPRO/SOC.P.REV.MED./1O Page 19 Occupational Health Lecture Laboratory practice Field visit Seminar 6. 11 hours Total 104 hours 21

Ratio lO.6i 21.4

4.5 3 3

33 24

9·1

12.5

Are there any traine d medical-social workers on the staff of 'the hospitals associated with your College? Yes, one in the Unit of Medical Social Work of the University nranch Hospital. Do

they take part in the tEaching of undergraduates? Yes, seminar on case work.

., ,

students carry out any home visits in the course of their clinical training? No, will be planned in the future.

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. No, planned but not yet realized.

~students

the

get any training in medical statistical methods?

Yes, statistical method is taught in pre-medical and preclinical period of medical course separately from the courses of Hygiene and Public Health. Health or medical statistical method is on schedule in the course of Public Health. 10. Is there a college (or student,) health service for the benefit of undergraduates? Yes, all the students of the University are covered by the Student Health Service. Comments and plans for the future Please make any comments here 1) If

relations •••

WPRO/SOC.PREV.MED./lO Page 20 1) If relations vith the local medical and health services are not sufficiently described above, please amplify here. Has no relation with local medical and health service as far as teaching and traininc activities of the students are concerned. 2) Do you consider the health services in your community adequate for

the field training of undergraduates in public health and preventive medicine? Such administrative system that community health personnel can hold an additional post in the university, will be helpfUl to the development of teaching in these subjects. Please describe any plans your College has for the development of teaching in these subjects. Intensive co-operative teaching should be established in conjunction with clinical medicine.

4) Please also describe the problems connected with recruiting suitable personnel who (with or without further training) might be entrusted with the development of such teaching. o~ a few studentsbecome. interested in the sUbject but few choose the subject as specialty after the graduation. The establishment of post-e;raduate course of public health in addition to the existing graduate course of Social Medicine ("social medicine" here is a collective name e;iven to a group of graduate courses including forensic medicine besides hygiene and public health) will be one of the possible ways to recruit suitable personnel for the teaching of these subjects.

...

WPRO/SOC.PREV.MED./10 Page 21 COLLIDE OF MEDIClllE, SEOUL NATIONAL UNIVK'ZSITY SEOUL, REPUBLIC OF KOREA 1. Has the College a specific programme for the training of undergraquate medical students in hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by f~culty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. Pre-clinical Year Sophomore l. Environmental Sanitation

,.,

2. Racial Hygiene 3. Medical Statistics and its Practice Clinical Years Junior l. Communicable Disease Control

32 bra 16 II

.. 4'

2 • Epidemiology 3. Industrial Medicine Senior

16 brs 10 II 6 II 24 brs

1. Public-Health Administration and Practice

Laboratory Works and Visits of Observation are required for sophomores. Examination of "\iater, sewage and air Food, milk sanitation and so on Visits of Observation i<

96 brs

32 brs

Teaching is done by faculty members.

Has the College a special teaching unit (department, division or section) dealing with these subjects? Yes. If so, what is the total number of professional/technical staff? The J:lepartment of Preventive Medicine deals with th2se subjects J the total number of professional staff is eight.

. 3.

How many qualified faculty members devote their whole time to academic work in these subjects? Eight. How many devote between half and all their time to these subjects?

.... L. What field •••

WPRO/SOC.PREV.MED./IO Page 22

4. ';Jhat field work do the students undertake in the course 0- their training in public health and preventive medicine? (a) visits of observation

32 hours are allocated for the visits. Hain objects are \-later supply system, sewerage, waste disposal" sanit2.tion in prison and plants and GO on. (b) takL~g part in cO@ffiunity health activities No.

Describe the attention paid to industrial hygiene (occupational health) tr~.ining.

Nothin" to be noted.

Arc there any trained medicctl-social workers on the starr of the hospitals a3socia ted nith your College? 1I0ne. Do they take part in the teachinf! of undergradua tos?

Do students carr;; out any home visits in the course of their clinical training? No.

Describe any co-ordinated t:;aching in curative and prev~ntive aspects, in medicine, surgery, ophthalmology, obstotrics, paediatrics, Gtc. 110thing to be noted. - --} '\ I

Do thJ students get anycraining in modical statistical mdhods? Yes, thGy get traininG. Forty-eight hours are allocated for this training. Topics arc on population, morbidity, mortality, standard deviation, chisquare and so on.

10.

Is there a college (or student) health service for the benefit of undergraduates? Yes, there is the Seoul IJational Univorsity Hi3alth Cunter. Comments and •••

WPRO/SOC.PREV.MED./10 Pe.ge 23 Comments and p12ns for the futuro PIGc:se make 2-n;,' CC'T'.fficmt::: here:If relations "i th tho local medical and h":'.l th s()n'ic;cs !U'C) :lot suff:'cicntly <icscribGd above, please amplify hare. Do you Gonsidur the hoal th son'ices in your community £:dequate for the field traininr of undorgr:ldua tes in p,'~)lic hc:c.lth and preventive medicine? Please describe any pl:::n3 your Collego has for the dovelopm(mt of teaching in these subjects. PI.:asc .'lIs 0 dc.':' cribe -~h(. r~'ob=,cms connected with recruiting suitable porso:1n0}, Hho (,Tie, or Fit:Oout further training) might be entrusted wi th thc dcvG:o~mc::-'.t of SUC:1 tC'~-G;1:n3 • 0

•

;;

WPRO/SOC.PREV.MED./IO Page 24

COLLEGE OF MEDICnrE, UNIVE.l'l.SITY OF THE PHILIPPTI:ES YlANlLA, PHILIPpnmS

Has the College a specific programme for the training of undergraduate medical students in hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by faculty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. Yes - See University of the Philippines College of Medicine Catalogue 1956-1957, Announcements 1957-1958 (However there are additions for the academic year 1957-1958 in faculty memberships which do not appear in the Catalogue for 1956-1957. These will appear in the Catalogue for 1957-1958 and Announcements 1958-1959. Courses Required for the Degree of Doctor of Medicine: (a) BACTERIOLOGY (Hygiene I-M). (Second year, 1st semester) 176 hrs. (2 hrs. lecture, 9 hrs. laboratory weekly). This course deals with the principles and methods employed in the study of bacteria, fungi, rickettsia'and viruses, their structure and properties which playa part in their pathogenic behaviour and the varied manifestations of the invaded host to their constituents and products. The host-agent relationship is taken up not only from the consideration of individual cases but also from the standpoint of the broad biological phenomena of disease incidence and prevalence. The course also deals with the principles of immunity and their application to medicine and public health. Lectures, recitations, assigned readin~s, laboratory work, demonstrations and fieldwork.

(b) PARASITOLOGY (Hygiene 2-M). (Second year, two semesters) 112

hrs.

1st semester - 48 hrs. (1 hr. lecture, 2 hrs. laboratory v[eekly) 2nd semester - 64 hrs. (2 hrs. lecture, 2 hrs. laboratory weekly) The course consists of lectures, demonstrations and lab.oratory work in Medical Protozoology, Helminthology and Entomology. In Medical Protozoology and Helminthology, the morphology, life history and the medical and public-health importance of protozoa and worm parasites infecting man are taken up. In Medical ••••

WFRO/SOC.PREV.MED./10 Page 25

In Hedical Entomology, the morphology, biology and control of the more important arthropods which are factors in disease causation and transmission are considered. (c) PRINCIPLFB OF HYGIENE AND PUBLIC HEALTH (Hygiene 3-M). (Third year, 1st semester) . 112 hrs. (2 brs. lecture, 5 hrs. laboratory and field-work weekly) This course introduces the medical students to the broad science of preventive medicine and public health. It is given jointly by several departments of the Institute of Hygiene. Students are acquainted with the different public-health activities and procedure, such as Vital Statistics, Epidemiology, Maternal and Child Health, Sanitation, etc. The duties and obligations of the practising physician to his patient and to the community with regard to health protection, promotion and conservation are emphasized. Lectures, recitations, laboratory and field work. (d) SPECIAL PROBLEMS m HYGIENE AND PUBLIC HEALTH (Hygiene 4-M). (Fourth year, 1st semester) 32 .brs. (2 brs. lecture and conference weekly) The course consists of lectures, demonstrations and conferences on special problems in public health. As part of this course, each student is required to make a sanitary survey of the city or town where he lives or expects to practi~e medicine or an environmental case study of a patient he has seen or studied in the hospitals in the form of brief reports. Interesting points in these reports are selected and presented to the class for discussion. 2. Has the College a special teaching unit (department, division or section) dealing with these subjects? Yes. If so, what is the total number of profeSSional/technical staff? Department of Hygiene and Preventive Medicine - 30 on full-time University appointment. In addition, several part-time public health lecturers are invited to supplement the offerings of the Department to further enrich the teaching ,dth varied observations derived from field experience. These full-time faculty members as ,well as the part-time lecturers, ho~,ever, do also teaching to graduate students and conduct research in the field of proventive and social medicine and public health. (See faculty record~ on file) •

How many ••••

WPRO/SOC.PREV.MED./10 Page 26

HOI-I many qualified faculty members devote their whole time to academic work in these subjects?

As stated above, 30 on full-time University appointment. HOI, many devote between half and all their time to these subjects?

~....

Six - of which two and a fraction

four are contributed by

rCA.

Here contributed by WHO; and

4. What field work do the. students undertake in the course of their training in public hGalth and preventive medicine?

.-.#

Theyspend one summer (approximately 100 hours or more) conferring with health officials ami doing field studies in public health in the community ,.here they expect to practise medicine after graduation, after which they present a public-health study report (reports may be seen on files of the Department). (See HYgiene 4-M of Catalogue. Copies of programme of this work is herewith attached, one for de,scriptive, the other for appraisal.) (a) visits of observation Professors by special arrangements take students to a number of health activities to observe certain phases of public-health Hork. (b) taking part in community health activities Hardly - except when they do public-health studies and are assigned to duty in the out-patient service of the Philippine General Hospit al. (University Hospit al) •

Describe the attention paid to industrial hygiene (occupational health) training. Industrial hygiene is coverGd generally in Hygiene 3-M and HYgiene 4-M, but not in great detail. Attention is merely called to occupational haza~ds and the principles involved in their prevention and control. The students are informed that those interested in industrial hygiene and medicine, if they wish, can pursue advanced studies in this discipline to prepare for a career in this field.

Are there any ••••

x One serves only one term.

WPRO/SOC.PREV.MED./I0 Page

Are there any trained medical-social workers on the staff of the hospitals associated with your College? Yes, as in the Tuberculosis Hospital (Quezon Institute), the National Mental Hospital, the Communicable Disease Hospital (San Lazaro), and the Demonstration Units. Hm-rever, in the University Hospital (the Philippine General Hospital), they were merely on special detail as was the case before -.Jorld War II. Do they take part in the teaching of undergraduates? Before World 1rJar II, medical-social workers in our Health Demonstration Units participated in field demonstration at these Units. Now that the Central University has a Division of Social Work with trained professional staff, arrangements are being made to have them take part in undergraduate instruction in medical-social work to medical and public-health students. However, careful selection of some well qualified who can teach (academically and personally) medical-social workers is a prime requisite otherwise this project will not prosper. (Presently we are not satisfied with the status of our medical-social instruction to our undergraduate medical students) •

ht .,

Do students carry out any home visits in the course of their clinical training? Yes, but not enough. NonEtheless, they do home visits in domiciliary service and in connection .rith the out-patient service of the Philippine General Hospital and in case studies aSSigned by the Department of Hygiene and Preventive Hedicine.

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. Our Department of Hygiene and Preventive Medicine extends fullest co-operation to other departments in matters involving approach to medical statistics, etc. (i) The Head of -ehe Department of Hedicine - (the Dean of the College himself) - "depending on disease being studied devotes 25% of his teaching to the consideration of matters bearing on some aspects of the prevention of such disease", and "15% on their social implications".

Similarly other ••••

....

WFRO/SOC.PREv.MED./lO Page 28

Similarly othe r Department Heads devote some part of their teaching as follows: Preventive Nedicine ( ii) Head, Department of Surgery

Social Medicine 10%

lOX; - 15% 2%

~ i' -'

(iii) Head, Department of E.E.N.T. (iv) Head, Department of Obstetrics (v) Head, Department of Paediatrics (vi) Head, Department of Gynaecology

2% 6%(x)

5% -

Often 10% 10%

20% - 24~

•

10%

T'le believe that if the clinical professors or even the pre-clinical professors are preventive and social medicine-minded, they cannot help but permeate and enrich their clinical teachin~ with the preventive and social aspects of disease.. Fortunately, all our clinical professors have been the students of the present Dean of our College of Hedicine and the Head of our Department of Hygiene and Preventive Hedicine and they are acquainted with their points of view on the subject. Even the heads of our pre-clinical departments devote a portion of their teaching to the consideration of the preventive and social aspects of medicine in the teaching of the ir subjects. Nevertheless, 'lIe are not content with the progress we he. ve already attained in this regard, and we are of' the opinion that a good deal more might be done to involve very much more the Department of Hygiene and Preventive Medicine in our regular clinico-pathological conferences (stUdents, faculty, and some physicians who are not at all members of our faculty) in the College Building, the clinical conferences in the hospital, and in our out-patient clinical teaching in the hospital as they are already involved in our regular faC'llty conferences and discussions.

. 9.

Do the students get any training in medical statistical methods? Yes. Preparatory to enrolment in the medical school, students take a required course in Elementary Statistics in the College of Liberal Arts. The course is a'50-hour lecture course offered by the Department of ~~thematics, and involves a study of frequency distributions, presentation of data, measures of central tendency and disperSion, the normal curve, sampling variation and simple correlation.

In the medical •••• (x)

Department Head reports t:1at in out-patient (dispensary teaching) majority of his tine devoted to preventive medicine.

WPRO/SOC.rnEV .MED./IO Page

In the medical school, the students take a course in biostatistics and epidemiology offered during the third year as part of the course in Hygiene 3-M - Principles of Hygiene and Public Health. The biostatistics portion of the course deals with population and vital statistics, rates and ratios, evaluation of public-health problems, "normal" values in medicine, and. clinical trials, in addition to a review of subject matter previously covered in the pre-medical statistics course. A total of 27 hours is devoted to biostatistics 11 lecture and 16 laboratory hours. It is planned to teach statistical methods applicable to laboratory data during the first two years of medical school through arrangements with professors pf physiology, pharmacology, pathology and microbiology. 10. Is there a college (or stUdent) health service for the benefit of undergraduates? Yes - the University Health Service of which our Manila Unit forms part - the cost of operation of the service is defrayed from regular student fees paid on a semestral basis - for periodic health examination and medical care including hospitalization. Comments and plans for the future Please make any comments hare, If relations uith the local medical and health services are not sufficiently described above, please amplify.here, Do you consider the hGalth services in your community adequate for the field training.of undergraduates in public health and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe the problems connected with recruiting suitable personnel who (with or without further training) might be entrusted with the development of such teaching. Our students (the 5th year) participate in the activities of the University Health Service and in some phases of the outpatient services of the Hospital. To a great extent in and around Manila, which are more easily accessible, if aGequately staffed can provide field training to undergraduate students in public health and preventive medicine. However, a very carefully planned and "ell SUpEr vis ed programme is necessary if good results would be expected. Lately (last week of July) in a conference convened and on mutual agreement among the staff of the Department of Hygiene and Preventive Hedicine (Institute of Hygiene), the Heads of the Department of Obstetrics and Paediatrics, respectively, the Manila City Health Officer, tho Chief of the ••••

,J:

WPRO/SOC.PREV.MED./l0 Page 30

Chief of thc Division of Training and Fnucation of the National DQpartmont of H()alth, and the Nation.:!l Director of H::alth and other authorities, it is hopod to organize special child and maternal health clinics for the purposes of study and training of students in this field, to supplement our hospital, dispensary, and health center facilities. The details of the plan are being mapped out. It is realized, however, that unless the facilities more particularly the staff of these clinics are augmented among others by additional well-trained and qualified instructors who will devote a great part of their time to study and teaching so that students might receive systematic individual attention, the mere detail of students to work in th;]se centers will not give the best results desired. It is also hoped that in the last clinical year (5th year) somo students desiring to pursue advanced stUdies in public health and prev;]ntive medicine and prepare themselves for a life's carGer in this field might be enabled to devote part of their time to an elective portion of their internship in preventive medicine and public health under the responsibility of the Department of Hygiene and Preventive Medicine just as they do rotating internships in the various clinical deparL~ents of our College. This, however, would require similarly a most careful study and planning on the part of the College authorities, our curriculum committee, the Department of Hygiene and Preventive 11edicine, and the National Health Department Division of Training and Education. For a number of years in tho past, as one official of the WHO vV-estern Pacific Regional Offico (Director of Health Services), will bear us out, we were not content with existing facilities for the teaching of preventive an~ social medicine as we could have this discipline learned by our students. In addition to the health department facilities in and around the City of Manila and in the Rural H3alth Demonstration ani Training Center, and the defunct Urban ikalth and Rural Health Jemonstration Units, before I-Iorld Har II, which the Head of our Department of Hygiene and Preventive Medicine had organized} the former (R.H.D.T.C.) having received assistance from ":rno and (JNICF;F, we had planned to take one whole province with all the municipalities in it, to organize its various health services, to augment its personnel and other facilities so that the same miglt serve as one of the principal components of our teaching facilities for preventive and social medicine. In this province our medical students as well as the doctors, nurses, he~lth educators, sanitarians and other health personnel in training, will be given more opportunities to learn preventive and social medicine by actual doing. It ·is only lately, last tJeek of August, that the Honorable, the Secretary of Health and the Honorable, the Provincial Governor, have approved the plan for this project as proposGd by a special committee created for the purpose. The close working

....

WPR/SOC.PREV.MED./10 Page 31

The close working relationship between the Department of Hygiene and Preventive Medicine and the Clinical and other departments of our College and the Division of Training and Education of our National Department of Health and the various City and other local health services around the Capitol area, and the trust and confidence reposed on our Department of Hygiene and Preventive Medicine by the Dean of our College augur well for the introduction of whatever further improvement might be introduced in our teaching of preventive and social medicine to our students as the advance of science and the needs of the community would dictate. After good planning must come good implementation, otherwise not much could be gained. Medical science is not static; neith(r medical education; much less the teaching of hygiene and preventive medicine. The scientist-educators must keep an open mind for whatever desirable changes become due for the better. Medical education must keep pace with the advance of science. This means progress. But there can be no progress without change. Yet not all change, however, is progress! They must not lose sight of the general objectives of medical education, the method of approach to the attainment of which, although based on certain approved prinCiples, will vary according to places, times and circumstances. Selection of well qualified personnel is not easy, nor is it easy to retain in the service for very long good men more specially if the standard of salary and other desirable inducements are not adequate. Neither is it easy to train staff members of a Department of Hygiene and Preventive Medicine or for that matter any department of a medical school. Consider the following views expressed by a noted educator, Glenn Frank, on this matter which should merit the attention of every teaching institution:"Portrait of a Good Teacher ll * IIGreat scholars are numerous. IIGreat teachers are rare. IIThere are probably fewer great teachers now than there were fifty years ago; there will probably be still fewer great teachers fifty years hence. The god of research is slowly but surely proselyting the follo\vers of the god of teaching. The teacher of 1850 'VIas mainly a man with an object. The teacher of 1950 may be merely a man with a subject. II Schools have t\-m. gigantic respons ibili ties, viz.: liThe responsibility •••

,,',_ • •

Philtppine Herald, 1926.

WPRO/soC.PREV.MED./10 Page 32

"The responsibility of investigation. "The responsibility of interpretation. "The man of tho laboratory may investigate. "The man of th8 lecture room may interpret. "The toacher has a different and, stall I say, diviner commission than either the investigator or the interpreter? "These men deal with the matter of their subject. "The teachor must deal ..rith the minds of his students. i

"Schools have many functions, but the:ir chief function is to furnish society with three sorts of servants, viz. " Investigators. "Interpreters~

"Inspirers. "Speaking rather loosely, for a moment, the teacher is of the third sort. "The teacher's primary business is that of a stirrer-up. "He is not, save secondarily, a salesman of knowledge. "He is, prirrarily a stimulator of curiosity. "But the great teacher manages to cOlllbine all tr.ree functions of his ministry to the minds of his students. "The great teacher is an investigator; he is not content to squat submissively behind the breast-works of accumulated kno..rledge; only so can he bring the spirit of intellectual adventure and conquest into his classroom; an incurious man cannot stimulate curiosity. "The great teacher is an interpreter; he not only knows his facts, but he knows what they are worth; he knows more about his own subject than anyone else, but he knows enough about other subjects to keep his own subject in perspective.

"The greater ••••

WPRO/SOC.PREV.MED./IO Page 33

II The greater teacher is in inspirer; he knows that the art of teaching lies in starting something in the student's mind; he is not content with merely putting into the student's mind, as a butcher stuf~s.a sausage skin.

"In short, the great teacher is a great man."

WPRO/SOC.P.REV.MED./l0 Annex I Page 1 UNIVERSITY OF MAIAYA

SINGAPORE

Teaching of' Social Medicine and Public Health to Undergraduate Medical Students 1.

All the teaching in the Faculty of' Medicine is integrated based on teaching in Pathology and covers a two-year cycle (i.e. 4th and 5th years). So far as possible the Department of Social Medicine confirms and lectures which do not fit the integrated programme are given yearly (e.g. nutrition and public-health statistics). An introductory clinical course proceeds clinical postings. In the curriculum in Social Medicine each student is required to a) Study and report on not less than two cases (chosen from any ward in the hospital, including medical, children, surgical, orthopaedics and eye, but usually one of'the studentd own cases is selected). For this he is required to make home visits (either accompanied or alone), to Gnquire into all relevant social, employment, economic and dietary factors and to give effect to his recommendations. One case covers a period of' 1.8 to 24 months observation, and the other is usually a shortterm problem (e.g. case of' a terminal illness). b) Once a week attend joint rounds in Medical Unit I (Professor Ransome), Medical Unit II (Prof'essor Monteiro), Paediatric Department (Dr. Elaine Field) where selected cases are presented by a student before clinicians and staff of department of' Social Medicine (usually, physician, almoner and dietitian). c) Perform and read 20 vaccinations against small pox.

3. • .

d) For one month of 'Whole time posting, undertake (either alone or in a small group) a public-health survey of a defined area. Students work under supervision but are encouraged to do all planning and administration themselves. e) From January 1958, attend well-baby clinic in the Institute of Health (staftred by Paediatric Department). Later, when introduced, each student may be required to attend a family clinic.

A list of lectures, demonstrations and visits

is appended.

J> ~ I

INTRODUCTORY COURSE -~-

"J:N'I1I:}RATED" TEACHING PROGRAMME

20TH MAY 1 1957. Vl-j

I" Part I

(1)

(2)

:D)

Nutrition (5) Part II

Public Health and Social Medicine (1) Social Aid (2) Housing (2) Talking to People (1) Society (1) Case Denonstration (1 (5) & (8) Kitchen Visit (1) Housing (1)

Disease spread by:Public-Health Water, food (1) Statistics ~8) Nutrition (6 vectors (1) Principles of Water supply and':Exc:reta Epidemiology (2) disposal (2) Disease spread by:- Dust DiseBfieQ of ~]. (1) contact (1) Tuberculosis (l.J air (1) Cardiovascllrar 2!seases(l) iiiiaria, Epidemiology and Control (2) Leprosy (1)

LE(tTUREl:l Genetics (3) Fi~iasis (1)

(5)

(bJ

Y':'Ws(l)

and C.W. (2) Family Planning (1) School Health (2) Family (1) iBadiation (1) Occupational Cancers (l)

~ternity

Adolescense (1) :Addictions (1) Accidents (1) Care of chroni c Work (1) invalids (1) Old Age (l.) ~ehabilitation Certification of (2) death (2) fE!'idemiology 0 f V.D. (1).

,..

(18)

(10)

(5)

(8)

(6)

(5)

DEMONSTRATIONS Air, Ventilation an Mosquito Breeding Sites(2) Dlind Home (1) Ifawkers, and eating Deaf Home (1) Lighting (1) (Demonstration Public Health Houses (1) Army Hygiene Unit (1) of aUdiometry) Statistics (2) Genetics (1) Nutrition (4) Public-Health Administration Seminar (1)

Clinic postings Infant Welfare "Family" Vaccination, D.C.G., etc. Factory (1) Seminar and Certification of Exercise (2) death (1) Seminar (1)

(1)

(2) ~-

(7)

(4) --

(4) ---

(1)

(:~)

(2)

WPRO/SOC.PREV.MED./l0 Annex II Page 1 FACULTY OF MEDICINE AND SURGERY UNIVERSITY OF SANTO TOMAS MANILA., PHTI.IPPINE3

Has the College a specific programme for the training of.undergraduate medical students in hygiene/public health/preventive medicine/socia! medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by faculty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. I

1957-58 PREVENTIVE MEDICINE I (IIIrd Year) (Se~estral - 102 hours) 1. 2. 3. Sanitation of water supply (analysis and interpretation) Food sanitation Sewage, garbage and rubbish disposal Disinfectants and disinfections Child and Maternal Hygiene Industrial Hygiene- Occupational Medicine Environmental Sanitation Vital Statistics and Biometry PREVENTIVE MEDICINE II (IVth Year) (Semestral - 102 hours) l.

5. 6. 7. 8.

Medical Entomology Epidemiology Prevention and Control of Communicable diseases Deficiency diseases Mental Hygiene Gerantology Immunology Public Health Administration and Public Health Laws Biochemistry~

Note:

Preventive Medicine is also touched in the subjects: Microbiology, Parasitology, and Protozoology in the I and II years, and Tropical Medicine in ~he III, IV and V years.

In the clinical years students are required to attend lectures on A.c.1'l1Jn:i."tration and organization of the different branches of the Government Department of Health. 2.

Has the College a special teaching unit (department, division or section) dealing with these subjects? ••••• If so, what is the total number of professional/technical staff? whi~h

The Faculty of Medicine has several teaching departments, one of is the Department of Preventive Medicine and Microbiology' The Section •••

WPRojSOC.PREV.MED.jlO Annex II Page 2 The Section of Preventive Medicine has ten (10) professional staff members-specialists and graduates of Public Health (C.P.H.); it has also six (6) technicians.

How many qualified faculty members devote their whole time to academic work in these subjects? None.

4. What field work do the students undertake in the course of their training in public health and preventive medicine? (a) Visits of observation Medical students do not undertake field work in the course of their training in publich6aLth and preventive medicine in the strictest sense~ Professors and specialists are invited from time to time to give pr~ical demonstrations in and outside College premises. Each professor is expected to bring his pupils to different branches of the Government for observation, or make irregular visits to industrial and food establishments, the Metropolitan Water District, in pre-assigned places for the demonstration of all types of toilets in the field. Also demonstration on the eradication of insects and rodents, appraisal of immunity of the population, epidemiological and statistical work. (b) ~aking part in community health activities

None.

Describe the attention paid to industrial hygiene (occupational health) training. Brief discussions on the history, development and relationship to general medical practice, of industrial hygiene in the Philippines. Thermal Standards in Industry;- space allotments - ventilation, etc. Principal industrial hazards - temperature - humidity - air motion atmospheric pressures - lighting - noise - dust - fUmes and gases radiation, etc. Industrial fatigue - most common occupational diseases; etiology, symptomatology, pathology, diagnoses, and general discussions on the ·treatment of occupational diseases of the skin, poisoning due to various substances as carbon mcnoxide, lead, arsenic, benzol the pneumcconiosis - agricultural chemicals and insecticides. The medical •••

. ,

. WPRO/SOC.PREV.MED./IO Annex II Page 3 The medical service in industry including labour, laws of the country, local regulations regarding plant sanitation - industrial accidents. Demonstrations of the most important industrial hygiene instruments as the sound lever metre, impinger, psychrometre, illuminometre, velometre, etc.

6. Are there any trained medical-social workers on the staff of the hospitals T

associated with your College? Yes, five trained medical-social workers.

Do they take part in the teaching of undergraduates? No.

7. Do students carry out any home visits in the course of their clinical training? No.

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. No formal co-ordinated teaching; as the different diseases are taken up, the preventive aspect of the treatment is emphasized.

Do the students get any training in medical statistical methods? The students receive training not only in Vital Statistics, but also in Biometry which covers the following: 1. methods of calculation of: Statistical constants measuring central tendency. Statistical constants that measure dispersion. Statistical constants that measure the shape of the variation curve. The Normal Curve (characteristics and uses). Proba~ility (limited to examples); The X test (example and uses). Linear Trend and Prediction (computation, examples and uses). Correlation of two variables (example and interpretation). Principles of a Life Table. Preparation of a COMMUNITY HEALTH MFI'RE. 10. Is there •.• Uses and a. b. c.

3. 4. 5· 6. 7· 8.

·. WPRO/SOC.PREV.MED./10 Annex II Page 4 10. Is there a college (or student) health service for the benefit of undergraduates? 'Yes, there is a Students' Clinic for the whole University population.

Comme.pts and p~ans for the future Please make any comments here. If relations with the local medical and health services are not sufficiently described above, please amplify here. Do you consider the health services in your community adequate for the field training of undergraduates in public health and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe the problems connected with recruiting suitable personnel who (with or without further training) might be entrusted with the development of such teaching. 1. The health services in some of our communities are adequate for field training of undergraduates in public health and preventive medicine. Future plans: a. A more effective integration of the teaching of preventive and curative medicine is contemplated. b. The inclusion of Sanitary bacteriology to the present course of preventive medicine is still under consideration. personnel for the faculty staff; in fact there are still three applicants with Master's Degree from American Universities that are being considered for appointment.

3. We do not have any problem in connection with the recruiting of

WORm HEALTH ORGANIZATION STUDY GROUP ON SCCIAL AND PREVENTIVE l-iEDICINE

REGIONAL OFFICE FOR THE 'WESTERN PACIFIC WPRO/SCC .PREV .l'1ED ./10 Add.l 17 OctDber 1957 ORIGINAL: FRENCH

Manila, Philippines 16-29 OctDber 1957

COMPIETED QUESTIONNAIRE ON THE TEACHING OF Prnl:VENTIVE .AND SCCIAL l:EII CINE FOR UIIDERGRADUATE MEDICAL STUDENTS ROYAL SCHOOL OF l'JEDIClNE PHNCl1-PENH, OOlBODIA

Has the College a specific programme for the training of undergraduate medical students in hygiene/public health/preventive medicine/oocia1 medicine? Describe the arrangements for the academic year 1957-1958. Please specify the teaching done by facul~ members and other persons and the time devoted to the teach~ of these subjects in the ~ eclinical years, and in each subsequent clinical year. Preventive and social medicine is actu~ the object of sp6cial teaching during the fourth year and last year of studies in the section leading to the diploma of "officier de sante". Two hours of courses are given each week to the students, bearing on general hygiene (public health) the prevention of infectious diseases, urban ani rural health, also social medicine. Practical demonstrations are given in the province in rural centres and in plantations (two or three times - demonstrations given by the lecturers).

Has the College a special teaching unit (department, division or section) dealing with these subjects? If so, what is the total number of professional/technical staff?

During the year 1955-1956, teaching was carried out by Professor Brwnpt" Professor of ParaSitology of the Faculty of l-iedicine, Paris. During the year 1956-1957 by Dr. Brumpt and Dr. }lIa].aterre.

3. How maru qualified faculty IOOmbers devote their whole time to acad!lJlic work in these subjects?

Dr. Maluterre will now be responsible for the teaching of hygiene and preventive medicine. 4. What field work do too students undertake in the course of their training in public health and preventive medicine? •••• This takes

wmo/soc.PREv.MEn./lo Add. I Page 2

This takes the form of visits, excursions in rural centres and plantations during which the students study general hygiene problems, rural and social ~d preventive medicine under the direction of a professor responsible for the hygiene course. In future years, an obligatory period of instruction (post-graduate) of three months will be organized in the Health Centre of Takmau for the officiers de sante just out of school. The officiers de sante stuqy regularly the health organization of the communities in their country under the dire ction of the professor responsible for the course.

5. Describe the attention paid to industrial hygiene (occupational health) trairWlg. This teaching will be included in the teaching of general hygiene given by the professor ani will increase in importan::e in accordance with the development of the country.

6. Are there aI\Y trained medical-social workers on the staff of the hospitals associated with your College? Posts of social workers h~ve just been created quite Ministry of Social Welfare. Do they take part in the teaching of undergraduates? With this new bod,y, the students of the Royal School of Medicine will benefit from practical teaching of these assistants under the direction of a professor. recen~

by the

Do students carry out aI\Y horne visits in the course of their clinical training? These last years, the students have undertaken visits to rural centres ani plantations.

Describe aI\Y co-ordinated teaching in curative and preventive aspects, . in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. The curative and preventive aspects of each of the disciplines have not been neglected at the School. Each professor in his discipline has directed his teaching not only to the curative but also the preventive aspects. • •• 9. Do the

WPRO/SOC.PREV.MED./la Add. 1 Page 3

9. Do the students get any training in medical statistical methods? During the year 1956-1957, Dr. Halaterre has given courses on statistical methodology.

10. Is there a college (or student) health service for the benefit of undergraduates? Yes. It is directed by Pathology.

Dr. Willm, Professor of Internal

and Tropical

Comments and plans for the future Please make al\Y cormnents here. If relations with the local medical and health services are not suffiCiently described above, please amplify here. Do you consider the health services in your communitcr adeqm te for the field training of undergraduates in public health arrl preventive mediCine? Please describe· any plans :rour college has for the development of teach~ in these subjects •. Please also describe the problems connected with recruiting suitable personnel who (with or without further·tre.ining) might be entrusted with the development of such teaching. Until now the teaching of preventive and social medicine has been given to the fourth year officier de sante students. A section of the doctorate of medicine now exists and in November 19'J7 studies in social am preventive medicine will be arranged for second year students. Fourth year students will be excused from teaching in preventive arrl sodal medicine and a postgraduate compulsor,r course will be carried out in the Health Centre of Takmau for doctors in medicine who haT e received diplomas from the Royal School of Medicine and wi sh to serve in the ranks of the Khmere .M.ministration •

...

WORLD HFALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16-29 October 1957

RIDIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./10 Add.2 17 October 1957 EN~L;r:sH

ONLY

COMPLEl'ED QUESTIONNAIRE ON THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS

Faculty of Medicine. University of Hong Kong 1.

Has the College a s:pe,cific programme for the training of undergraduate medical students in hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic year 1957-58. Please specify the teaching done by faculty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each sUbseq.uent clinical year. There is a specific training programme for undergraduates in medicine, in all above subjects. For the present, and temporarily, the staff in the Department of Social Medicine, is entirely part time. The majority are members of the government Medical Department. The teaching is done in the third and fourth years (of a fiveyear course). The third year is mainly Clinical, the fourth is entirely clinical (except for social medicine) • The course consists of 71 hours 'of lectures and demonstrations, plus visits to various points of importance, accompanied by a staff member, where health projects are being carried out. In such visits the class is usually divided into small groups of about six each. The subjects dealt with are listed on the attached schedule (Annex I).

Has the College a special teaching unit (department, division or section) dealing with these subjects? •••••••• If so, what is the total number of professional/technical staff? Department of Social Medicine and Public Health. About thirty part-time lecturers and demonstrators, the large majority of whom are government medical officers and specialists.

3. How many qualified faculty members devote their whole time to academic work in these subjects? Temporarily none. 4. •

What field •••

{ ..

WPRO/SOC.PREV.MED./IO Add.2 Page 2

What field work do the students undertake in the course of their training in public health and preventive medicine? Visits of observation are made to a number of centres where such public-health activities as mosquito control, water filtration and chlorination, meat inspection, etc. are being carried on.

5. Describe the attention paid to industrial hygiene (occupational health) training. Visits are made to a limited number of factories to check on health hazards, etc.

6. Are there any trained medical-social workers on the staff of the hospitals associated with your College? Yes - almoners Do they take part in the teaching of undergraduates? Some of them /

Do stUdents carry out any home vi si ts in the course of their clinical training? Yes, in company with almoners.

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. In tuberculosis and in obstetrics (pre-natal clinics) there is considerable time given to preventive aspects; also in the teaching of other infectious diseases (typhoid, the dysenteries, diphtheria, leprosy, etc). Every student spends a week in the Leper Hospital during his final year, during which time there is an intensive course on the social aspects of leprosy as well as on its clinical.. Problems of nutrition are dealt with early in the course, during classes in biochemistry.

Do the students get any training in medical statistical methods? Yes - lectures only

10. Is there a college (or student) health service for the benefit of

undergraduate s1 Yes, with full-time physician and nurse in charge. Connnents and ••• • /I

WPRO/SOC.PREV.MED./l0 Add.2 Page 3

•

· ..

-<-

WPRO/SOC.FREV.MED./10 Add.2 ANNEX I

UNIVERSITY OF HONG KONG SYLLABUS OF LECTURES ON SOCIAL MEDICINE AND PUBLIC HEALTH - 1957-1958 TOTAL: INTRODUCTORY a. b. What is Social Medicine? Social Medicine and Human Welfare.

71 HOURS

NUTRITION AND HEALTH a. Sociology of Nutrition - malnutrition as a world-wide problem relation of income and family size to food consumption - production and distribution of food-nutrition and mortality. Science of Nutrition as applied to Groups - ascertainment of nutritional status, recommended dietary allowances _ nutritional problems of rice eating countries. Nutrition and Public Health - nutrition policy - rationing systems and food control - feeding programmes.

ENVIRONMENTAL SANITATION: a. b. c. d. e. f. g. Water supply Sewage

and refuse disposal

Milk, food and meat hygiene Housing, ventilation and lighting Rodent and insect control Sanitary inspections and regulations Arthropod pests (excluding mosquitoes) of public-health importance

VITAL AND MEDICAL STATISTICS Introductory and historical, registration of births and deaths, notification of disease, records of illness in hospitals, industries etc., health surveys. Morreli ty and morbidity: sex, age, occupation, social class or economic status, crude and standardized death-rates. Rates in common use. Population: •••

WPRO/SOC.PREV.MED./10 Add.2 Annex I Page 2 Population: census and methods of estimation of population.

..,. •

World population. Methods of presentation of numerical data: distribution, charts and graphs. Averages: mean, median, mode. tabulation, frequency

Measures of dispersion, range, mean d.eviation, standard deviation, coefficient of variations, normal distribution. Sampling: random sample, standard errors of the Mean, proportion and differences. Common fallacies and difficulties. EPIDl!MIOLOGY AND COMMUNICABLE DISEASE CONTROL Principles of Epid.emiology and Control of Communicable Diseases: 1. 2. Principles of Epid.emic Prevention and Communicable Disease Control Epid.emiology and Communicable Disease Control in local practice and Control of Air-Borne Infections

~id.emiology

1. 2.

3. 4. 5. 6. 7. 8. 9.

Smallpox and chickenpox Diphtheria Streptococcal infections - respiratory Measles Whooping cough Cerebrospinal meningitis Influenza Poliomyelitis Common cold. and Control of Alimentary Infections

~idemiology

4. 5. 6.

Cholera Typhoid and para-typhoid fevers Dysenteries: a) Bacillary dysentery b) Amoebic dysentery Infective enteritis of infancy Food poisoning House fly (Musca domestica) and Control of Insect-Borne Infections

~id.emiology

1. 2.

3. 4. 5.

Plague Rickettsial Diseases, e.g. Typhus fever, relapsing fever Malaria (Mosquito) Yellow fever Dengue fever Japanese B. encephalitis Epidemiology and •••

WPRO/SOC.P.REv.MED./lO ~dd.2 Annex I

Page 3

§Pidemiolo gy and Control of Social Diseases 1.

3. RABIES

Tuberculosis Venereal diseases Leprosy

PUBLIC-HEALTH SERVICES

a. b. c. d. e. f.

g. h. i. j.

Functions and organization of public-health services Principles of health education Ma. ternal and child health School health Industrial health Port health Mental health International health Health visiting Medical social work.

WPRO/SOC.FREV.MED./10 Add.2 ANNEX II

REPORT OB THE DEPARTMENT OF SOCIAL MEDICINE, UNIVERSITY OF HONG KDNG* Functions of the Department of Social Medicine Before setting out a statement on the functions of the Department of Social Medicine it would be advisable to define our concept of social medicine. We cannot do better than to quote the following from Prof. Ryle, the founder of the Oxford School of Social Medicine: "We should recognize first that any discussion on the theory and practice of social medicine must take place against the background of a social order in which health and disease patterns are continually changing; and, second, that the theories of medicine of the last three centuries can no longer cope with our changing society and must be modified and extended. ~

Attention must be shifted to the study of the healthy citizen and the effects of both heredity and environment, with special reference to york and .life in various cOIlllllunities. We can study him both as an individual and as a member of a group, but we must synthesise these studies and not ignore social aspects in the study of the individual. In the study of man as a social being, we must concentrate on the cOIllllloner diseases. We must examine these diseases in their social setting, in the life of the cOIlllllunity, as well as by the bedside and in the laboratory, for they have their social causes as well as their individual causes. Prevention depends largely on dealing with the social causes. We must not, however, restrict our examinations to social pathology, i.e. to a study of the end-results of these conditions or their death-rates. We must direct our investigations to the detection of their early beginnings, to a stage when we have a chance of curing them •

..,

The help of all health workers, and the general public, must be enlisted. The measure of success will often be determined by the extent of team-work contributed by ordinary health workers and citizens, as well as physicians and social technicians. Moreover, there are many health problems in society which have already been solved in theory, but which still-remain because no social action has been taken; there is a long delay between discoveries in medicine and their general application. Finally, great efforts must be made to educate the public, medical students, health workers, and the present generation of doctors, in the need for this new approach to health and sickness. The health services must become an integral part of the life and work of the co!lllllunity, and the community must help in the work of the health services." The functions of the Department of Social Medicine, based on the above concept of Social Medicine, would be: (1) Teaching •••

*Adopted

by the Board of the Faculty of Medicine. To be considered by the Senate, probably in November, 1957.

WPRO/SOC.PREV.MED./IO Add.2 Annex II Page 2

(1) Teaching medical students this new approach to health and sickness, with special emphasis on the holding of group discussions on important he~lth subjects, ,field work and investigation, visits to institutions connected with social or health work, visits to patients' homes with trained almoners, and the bedside teaching of social medicine in connection with the teaching of clinical subjects. (2) Doing research work on the social conditions Which affect the health of the community and on the local preventive aspects of disease. (3) Instituting, if considered desirable, a post-graduate course for the Diploma in Public Health, and other health courses, e.g. for health visitors and health inspectors. Hong Kong Application Hong Kong's overcrowded living conditions and population problems are too well known locally to require elaboration. Less well-known and understood by the public are the numerous health problems associated therewith and the constant public-health measures of both preventive and remedial nature that are necessary to safeguard and improve the health of the population under these conditions. Approximately 9"/0 of the Colony's total estimated revenue is expended in meeting these problems. Thus, for example, preventive measures constantly in effect have protected the Colony from diseases such as smallpox, cholera, epidemic typhus, plague, yellow fever and relapsing fever -- an epidemic of any of which can be disastrous. Control measures for enteric fever, such as the periodic immunization campaigns, produce a definite arrest in the prevalence of the disease. The tuberculosis death rate in the Colony is high, still exceeding 100 per 100,000 population and a recent statistical report compiled by the World Health Organization indicates that chances of infection in Hong Kong, with a high death rate, are greater than in a.ny other country covered by the report. HygieniC measures applicable in the home are among the most effective measures of prevention ~k1ng against the spread of the disease in crowded living conditions. These are representative of but a few of the problems met and dealt with in social medicine. They, and many more, are problems that the medical graduate should be familiar with if he is to make his best contribution to his profession and his community. Knowledge of and interest in them cannot be ade-_uately provided by lectures only. The student must see the problems and the methods used to solve them, and, where pOSSible, gain some experience through participation. A single hour's demonstration of the health problems of a tenement area, or of a squatter village, or of a sewage disposal system, can be far more productive of thought and understanding than many hours of lecturing on the same subjects. The greater portion of the medical student training is in the laboratories, the hospital wards, and the out-patient clinics. These disciplines by themselves cannot give the student an adequate concept of the role of his profession in the life of the community. A function of an adequate department of social mediCine is to

',.

...

, WPRO/SOC.PREV.MED./IO Add.2 Annex II

Page .3 medicine is to provide the student with a broader contact with his comnnmity in a medical sense, and to stimulate in him a greater vision of his role as a citizen for whom the community has helped to provide a specialised education dealing with problems essential to the survival and well-being of the community. The University also has a broader responsibility to the community with respect to these problems. The community and government have a right to expect that the University will concern itself with also making contributions to an understanding of the problems of social medicine. Research and other contributions from many of the departments of the UniVersity are indeed fundamentally applicable to the problems of social medicine, but there are many problems peculiar to this practice that will not be touched on by other departments and Which require the development of a vigorous department of social medicine if the University is to meet its responsibilities in this respect to the student and the community. These responsibilities cannot be met by the appointment of a part-time professor only, as the past fi~e years have demonstrated. The history of the Department of Social Medicine at the University of Hong Kong indicates that the University sensed this responsibility several years ago. Various exigencies, however, have subsequently resulted in a retrogressive rather than a progressive development of this department. It is the considered opinion of the Faculty of Medicine that a serious re-evaluation and progressive strengthening of this department is at the present a major responsibility of the University. History of the Department

Dr. D.J. Sloss, the former Vice-Chancellor, created this Department by appointing Dr. T.S. Sze to the Chair of Social Medicine. Dr. Sze was given a scholarship in 1948 to work under Professor J.A. Ryle of Oxford and to visit the social medicine departments of Edinburgh and Birmingham universities before he took up the Chair in July 195('. He held the post for two years, but he had no supporting full-time staff. As he was single-handed, he appealed to the Director of Medical and Health Services for part-time staff to help him in giving lectures, demonstrations and field visits to the students, and realising his difficult pOSition, the Director of Medical and Health Services requested several of his health staff to help him. Dr. Sze eventually resigned in July 1952. Dr. K.C. Yeo, Director of Medical and Health Services, was then approached by the Dean of the Medical Faculty to take up the post and was appointed parttime Professor. Dr. Yeo is retiring in July 1957. Necessary Developments of this Department if it is to perform its Functll·.-·ns To perform its functions properly, the Department should be adequately staffed, accommodated, and equipped both for teaching and research. Recommended full-time staff 1 Professor

2 Lecturers 1

Clerk •••

wPRO/SOO-~PREV .VJID..jlO Add. 2

Annex.U· Page

l 1 2 2 AccolllIllodation

Clerk Artist Laboratory Technicians Laboratory Attendants

l Office/Laboratory for Professor 1 Office for Clerk 2 Office/Laboratories for staff at 350 sq. ft. 1 Museum/Demonstration Room with Chart Room for Artist l Technicians' Room 1 Store Room 1 Dark Room Total:

lBo

350

700 750 200

lBo

300

2,.660 sq. ft.

Sgd:

.A.J.S. McFadzean professor of Medicine Olaf. K. Skinsnes Senior Lecturer, Department of Pathology & Bacteriology

Sgd:

K.C. Yeo Professor of Social Medicine

WORLD HEALTH, ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./IO Add.3

17 October 1957 ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957

COMPLEI'ED QUESTIONNAIRE ON THE TEACHING OF PREVENl'IVE AND SOCIAL MEDICINE FOR UNDERGRADUATE MEDICAL STUDENl'S UNIVERSITY OF OTAGO MEDICAL SCHOOL

Has the CollBge a specific programme for the training of undergraduate medical stUdents in hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic year 1957-1958. Please speci~ the teaching done by faculty members and other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year. Yes: comprehensive integration with faculty members.

The Staffing of the Department The Department of Preventive and Social Medicine is a speCial department of the School with a whole-time professor, a fulltime senior lecturer, 2 whole-time lecturers and 4 part-time lecturers including the Medical Officer of Health, the Vital Statistician of the Department of Health, the Industrial Health Officer and a School Medical Officer. The non-medically qualified staff include a public health nurse whole-time and a secretary. Functions A specific programme for the training of undergraduate medical students is carried out throughout the three terms of the fifth year in accordance with the attached statement. In addition to this teaching in the fifth year some instruction is given to students of the second and third years at the time of their routine medical examin2tions when routine X-ray and Mantoux testing is carried out, also B.C.G. vaccination and smallpox vaecination where indicated. In the fourth year in the Microbiology course theoretical and practical instruction is given in the epidemiology of the infective diseases. Practical "i'Tork The Department is responsible for the preventive and therapeutic work of the University Health Service and is also responsible for the Bchool health activities of a district of sqme 12 000 people ••• with a school

WPRO/SOC.PREV.MED./10 Add.3 Page 2 with a school population of 2500. The schools concerned include a kindergarten, 2 primary schools, an intermediate and a secondary high school. The students attend the health clinic at the Medical School in groups of four for practical and clinical work in this service. There are four consulting rooms in the clinic where the student carries out his examination in private as if in his own practice. The student is responsible, under supervision, for the routine examination of school children with the parents present. During his attachment to the health clinic the student participates also in the Ante-natal and Post-natal Clinics of the University Maternity Hospital. Visits are also made with the Industrial Medical Officer to selected factories within the area. Once a week a round-table discussion is held with the students and representatives of the various educational and social agencies working in the field of health in the district and with the Departments of Paediatrics, Psychiatry and Medicine. In addition to the above mentioned activities each student is required to undertake a practical study in some aspect of the subject according to the student's own interests. This work is in the main carried out in the long vacation between the fourth and fifth years of the medical course. The student presents a thesis at the end of the year which is required to conform to the technical requirements for publication in a scientific journal. In the course of the thesis the student receives training in medical statistical method and in the majority of cases home visits under supervision are required to be carried"out in the course of the study. (See also Annex I) 2. Has the College a special teaching unit (department, division or section) dealing with these subjects? If so, what is the total number of professional/technical staff?

(a) (b) (c) (d) 3.

Yes: Department of Preventive Medicine Professor Three full-time professional staff. One half-time in addition. Two and one-half time - technical.

How many qualified faculty members devote their whole time to academic work in these subjects? (a) (b) Professor Three full-time professional staff

How many devote between half and all their time to these subjects? Three 4. What field work do the students undertake in the course of their training in public health and preventive medicine? Each student required to present practical study written as per publication in form of thesis. . •• (a) visits of

WPRo/soc PREV MED 110 Add.3 Page 3 (a) visits of observation i. ii. One week observation in health clinic under conditions of normal practice. Attachment to general practitioner service.

(b) taking part in community health activities i. ii. iii. iVa 5. Antenatal and post-natal clinic Infant welfare clinic Pre-school and school clinic University health service

Describe the attention paid to industrial hygiene (occupational health) training. (a) Lectures by Occupational Health Officer (b) Visits to industry

Attention paid is in relation to importance. Training of general practitioner in supervision of health of industrial worker and alerting practitioner to the industrial disabilities he may meet in practice.

Are there any trained medical-social workers on the staff of the hospitals associated with your College? Yes. Do they take part in the teaching of undergraduates?

Yes.

Do students carry out any home visits in the course of their clinical training? Yes.

Describe any co-ordinated teaching in curative and preventive aspects, in mediCine, surgery, ophthalmology, obstetrics, paediatrics, etc. (a) (b) Health clinic activities co-ordinate all governmental voluntary organization working in preventive field. Co-ordinated teaching in all fields of medicine (tuberculosis control, ophthalmology, obstetrics and paediatrios). See 5(b) •

.•. 9.

IX> the

...

WPRO/SOC.PREV.MED./10 Add.) Page 4

Do the students get any training in medical statistical methods? Yes. (a) (b) Practicel in consultation with medical statistician in preparation of individual theses. Lectures by official Government Statistician in indices.

10.

Is there a college (or student) health service for the benefit of undergraduates? Yes.

". I

. WIRO/sec .PREV .MED./IOAdd.3 ANNEX I PREVENTIVE AND SOCIAL MEDICINE (Professor Sir Charles Hercus and Staff) The Class for Degrees in Uedicine meets three days a week during Autumn, Winter, and Spring Terms I. The Lectures treat of :

General Conditions. - Historical background, problems of health and disease. Maternity, Infant and Child Welfare. - Ante-natal care, hygiene of maternity, maternity mortality. The hygiene of infancy, of children (1-5 years) • disease~

School Hygiene. - Health requirements of children. The beginnings of The dull and backward child. Special schools. Physical education. Industrial Hygiene, Vocational Guidance. - The maintenance of health The prevention of diseases of occupation.

in the industrial environment.

The Hygiene of Adult Life, including Old Age. Environment Problems. - Town-planning and housing. Milk supp~. Pure foods. Food poisoning. Deficiency diseases. viater supply, sources, pollution, purification, water-borne diseases. Infectious Diseases and Epidemiology. - Principles of epidemiology. Methods of control of infectious diseases. Disinfection. Sanita~ Law and Vital Statistics. - Health legislation. Legal obligations of the general practitioner. Vital statistics of importance to the medical practitioner.

Medico-sociological Problems in Relation to General Practice. - The general practitioner and his relation to health education, health insurance and mental hygiene. II. Practical Work

Students are required to attend all sessions for clinical work arranged for them by the Department. Each student is required to car~ out a practical exercise in the subject, to write a thesis, and to present his findings to the class.

· 4

i-l)RLD REA.LTH ORGANIZATION REGIONAL OFFICE FOR THE WES'IERN PACIFIC I'lPRO/SOC.PREV.MED./lO Add.4 18 October 1957 ORIGINAL: FRENCH

S'lUDY wtOUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16-29 October 1957

COOPLE~ QUESTIONNAIRE ON 'IHE 'IEll.CHING OF PREV~;TI\JE : ..ND SOCIAL MEDICINE FOR UNDEHGlliillUA 'IE ~EDIc.:.L STUDENTS

Faculty of Medicine and Pharmacy, University of Saigon

Has the College a special te~ching unit (department, division or section) dealing with these subjects? ••••••• If so, what is the total number of professional/technical staft? A department of preventive medicine is in course of organization. 111e teaching personnel consists at th e moment of tvlO persons I . one full time and one part time. We are planning to increase this number when pos si b1.e •

How ma~ qualified faculty members devote their whole time to academic work in these subjects? One. How ma~

devote between half and cl.l their time to these subjects?

One.

14hat field mrk do tlE students undertakE in the course of their training in public health and preventive medicine? (a) visits of oboorvation

WffiO/SOC.ffiEV.MED./10 .Add.4 Page 2 (a) visits of observation Field visits have taken ploee every year while awaiting the opportunity to organize meetings of propor practical work. (b) taking part in community health activities Onl,y \{)luntary students participate in occnpational health activities organized by tre Minister of Health or the Social ivelfare Departmant of the Presidency of the Republic during the period of long vacation.

Describe the attention paid to industrial hygiene (occupational health) training. Theoretical trnining: health. tvrenty four hours 0

f courses in occupational

Field visits: different factories, water works, municipal slaughter houses, municipal garbage depots, breweries and icehouses.

1.re there artY' trained madical-social workers on the staff of the hospitals associated with your College? Yes. Do they take part in the teaching of undergraduates? No.

Do students carry out any home visits in the course of their clinical training? Not for the moment.

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. There is not, to be exact, a co-ordinated proeramme of pre venti ve madicine combining the various disciplines: madicine, surger,y, ophthalmology, obstetrics, paediatrics, etc. but the teaching of each branch of madicine covers at the same time curative and preventive aspects.

Do ihe students get any training in madical statistical methods? Not for the moment.

10.

Is there a college (or student) health service for the benefit of undergraduates? Yes. Comments and plans

WPRO/SOC.PREV.MED./l0 Add.4 Page 3 Comments and plans fur the future Please make any comments here. If relations with the local medical and hoal.th services are not sufficientJ.y described above, please amplify here. Do you consider the health services in your community adequate for the field training of undergraduates in putilic health and preventive medicine? Please describe aqy plans your College has for the development of teaching in these subjects. Please also describe the plDblems connected with recruiting suitable personnel who (with or without further training) might be entrusted wi. th the development of such teaching.

I I

WORLD HEALTH ORGANIZATION

REG IONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./10 Add.5

AND PREVENTIVE

STUDY GROUP ON SOCIAL MEDICINE

31 October 1957 ORIG!HAL: ENGLISH

Manila., Philippines 16-29 October 1957

COMPLETED QUESTIONNAIRE ON THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS

Central Medical School, Fiji 1.

weekly lectures during the three terms of 2nd yea:r 13 x 3 = 2iI hours. weekly lectures during the three terms of 4th year 13 x 3 = 39 hours.

Once

Two weeks in 4th yea:r and two weeks in 5th yea:r of practical w:>rk in preventive medicine (full time) All clinical teachers (particularly in Clinical Medicine, Tuberculosis and Leprosy) stress the social and preventive factors in their teaching. is carried out by an instructor who is a full-time teacher of Sanitation. is carried out by a medical officer of health. is variously done by members of the Health Department.

a. b. c.

Preventive Medicine is emphasized by being a separate paper in the final qualifying examination, being of equal importance with Clincal Medicine. 2. Has the College a special teaching unit (department, division or section) dealing with these subjects?...... If so, what is the total number of professional/technical staff? Not yet. 3. How many •••

WPRO/SOC.PREV.MED./IO Add.5 Page 2

3. How mapy qualified faculty members devote their whole time to academic work in these subjects?

How many devote between half and all their time to these subjects?

4. What field work do the students undertake in the course of their training in public health and preventive medicine? (a) visits of observation Water supply, meat inspection, ship inspection School and infant health services, building inspection Vaccination and immunization, court procedures Village sanitation projects (b) taking part in conmnmity health activities This is just starting and we hope to extend it very greatly.

5. Describe the attention paid to industrial hygiene (occupational health) training. Nil as yet.

6. Are there any trained medical social workers on the staff of the hospitals associated with your College? No.

Do they take

part in the teaching of undergraduates?

7. Do students carry out any home visits in the course of their clinical training? Not yet.

Describe any •••

WPRO/SOC;PREV.MED./lO Add.5 Page 3

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc. Ini'ormal only.

9. Do the students get any training in medical statistical methods? Negligible. lO. Is there a college (or student) health service for the benefit of undergraduates?, Yes.

Co-ordination and integration with clinical teaching.

WORLD HEALTH ORGAm:ZATION STUDY GROUP ON SOCIAL AHD PREVENTIVE MEDICINE Manila, Philippines

REmONAL OFFICE FOR THE WESTJ!RN PACIFIC

WPRO/SOC.PREY' .MEn./ll 2 October 1957 ORIGINAL: 1iBGLISH

16-29 October 1957

MEDICAL EOOCATION IN COMPLErE MEDICAL CARE* prepared by the

Camd ttee on the Family Health and MecU.cal Care Prograzqme**

CONTENTS ~

~ 1 2

THE FAMILY HEALTH PROGRAMME THE EWCAfiONAL PROGRAMME POST~TE

3 4

EDUCATION

RESEARCH

*Unpublished reference on a. Ha.rva.rd progra.llllDe **Ha.rva.rd Medical School, Massa.chusetts, U.S.A. '!his paper vas not prepared expressly for the Study Group but is submitted for information of the participants.

COMMITl'EE ON THE FAMILY HEALTH AND MEDICAL CARE PROGRAMME

MEMBERS

Walter Bauer, M. D. Professor of Medicine, Harvard Medical School Chief of Medical Services, Massachusetts General Hospital George Packer Berry, M. D. Dean of the Faculty of Medicine Harvard University Allan M. Butler, M. D. Professor of Paediatrics, Harvard Medical School Chief of Children t s Medical Service. Massachusetts General Hospital

Dean A. Clark, M. D. General Director Massachusetts General Hospital Stanley Cobb, M. D. Professor of Neuropathology, Harvard Medical School Chief of Psychiatric Service Massachusetts General Hospital Henry C. Meadow Assistant :D9an of the Faculty of Medicine Harvard University David D. Rutstein, M. D. Chairman

Professor of Preventive Medicine Harvard Medical School

WPRO/soc .PREY' .MEn./ll Page 1 The Harvard Medical School has as a first responsibility the training of the "complete phys'ician"--one 'Who ideally provides complete medical care to his patients by marshalling for their benefit all preventive and curative in-. formation and skills and all available personnel and facilities for preventing and treating illnessj and 'Whose interest in his patients and their families makes it possible for him to recognize the social, environmental and medical factors concerned with the cause and evolution of the patient I s illness and their influence on his medical care. This educational objective must be considered in the light of changes that ha.ve occurred in medical education since the turn of the century. At that time the Flexner Report was instrumental in converting a training programme based on symptomatic treatment of patients into an educational programme based on pathologic. . physiology. This change resulted in a flowering of medical research in the laboratory and cliniC, with the simultaneous development of specialized medical practice. These trends ha.ve in t1.ll'n led to the development of the teaChing hospital, 'Where medical students receive instruction from a group of specialists 'Who co-operate in the treatment of the patient, but 'Where no one physician accepts responsibility for continuity of his medical care. Over this same period the characteristics of the general population have changed. The patient population of the teaching hospital has also changed, perhaps even more rapidly. It has become markedly less representative of the complete spectrum of illness as seen by the practising physician. Due to an aging ~opulation with concomitant increase in chronic illness, the home treatment of acute illness with new and effective therapeutic agents, and the increasing cost of hospitalization, hospitals (particularly teaching hospitals) are filled with a highly selected group of severely ill patients. Many are older people with chronic disease, patients with serious complications of acute illness, and those with rare diseases. Furthermore, hospital teaching has concentrated on the well-studied bed patient, with particular emphasis on serious, often fatal illness as exemplified in the clinico-pathological conference. In this teaching environment the tmd.ergraduate receives little training in the recognition of the earlier stages of illness, 'Where most can be done for the patient, or in the emergence of disease from a well population; 'Where preventive medicine is most effective. Ambulatory medical care is taught in the out-patient services of hospitals but does not usually receive the emphasis given to in-patient teaching. In this Medical School, such teaching is usually conducted by the least experienced members of the Faculty, in rather erratic fashion, and due to transient assignment of students and resident staff, does not provide for observation of the evolution of illness over any significant period of time. Recently some of the teaching hospitals have attempted to improve out-patient instruction. This is ftmd.aJnental, but is only the first step in any plan for teaching complete medical

care. If the student is to tmderstand the natural history of individual illnesses and his responsibility in the maintenance of the health of and treatment of disease in his patients, he must also have opporttmities to observe the emergence of disease in well populations and to study the ecologic factors Which affect the occurrence and course of illness. If he is to learn to practice the complete medical care that should be the responsibility of

WPRO / soc . PREW •MElD •/11 Page 2

responsibility of the family physician, he must have experience in maintaining continuity of medical supervision of ratients and in correlating available community services and personnel for their benefit. Clearly, such experience is.impossible if his education is confined to extensive training in diagnosis and management of hospitalized patients, with very little training in care of ambulatory ratients, and no training at all in care of the sick in their homes or in supervision of healthy members of their families. But complete medical care might be taught if there were, in addition to the present educational programme, a medical school-hospital sponsored plan of complete medical care for family groups, into which students could be introduced early in their preraration for the practice of medicine. This proposal is made with full. realization that medical education must continue to emphasize research and instruction in scientific medicine and without diminishing this effort, must also provide an opportunity for teaching its effective application for the maintenance of health and the treatment of illness. The Faculty of the Harvard Medical School, having studied this problem, voted to conduct an experiment in the education of students in complete medical care, to be begun first at the Massachusetts General Hospital, the Trustees of that Hospital having given prior expression of their approval and active support. In this experiment, a sample of medical students is to be trained by assignment to a family receiving complete medical care from the staff of the Hospital and of related community agencies in the home, a reorganized outpatient department and the ward. 1. THE FAMILY HEALTH PROGRAMME

The first stage in the development of the educational programme for the medical. stUdent is to establish a smoothly functioning complete medical care service, a Family Health Programme, providing care on a 24-hour basis to a group of families living in the vicinity of the Massachusetts General Hospital.. This programme will llrovide to the family, the "medical care unit", continuity of health supervision, all specialized services available at the Massachuaetts General Hospital and other medical institutions, and co-ordination of all pertinent auxiliary medical services and community health facilities. It will " also make available for teaching, research and medical care the skills existing in other branches of Harvard University, including biology, sociology, anthropology, biostatistiCS, epidemiology, experimental psychology and other appropriate disciplines. The Family Health Programme is to evolve from the present programme developed by the Department of Paediatrics at the Massachusetts General Hospital and will involve co-operation with the Blossom Street Health Center of the Boston City Health Department, the Boston Visiting Nurse Association and the" social workers of the Department of Public Welfare of the City of Boston. In this paediatric programme, children have been given treatment in the hospital on a 24-hour basis and out-patient and home care services during the day, with continuity of medical care as a major objective. It is proposed to build upon this by offering complete medical care to all membe~s of the families of these children, while extending the service to include other families whose members are being cared for by any of the services of the Hospital and those admitted I to the obstetrical •••

)

WPRO/SOC.PREV.MED./ll Page , to the obstetrical care services to be provided in connection with the prenat41 clinics at the Massachusetts General Hospital and Blossom Street Health Center and the Obstetrical Services of the Boston Lying-in Hospital. All services at the Massa.chusetts General Hospital and at the Massachusetts Eye and Ear Infirmary will be represented either by actual membership in the unit or by liaison through a designated member of the respective service. Liaison will also be effected with the practicing Physicians in the geographic area served by the programme. . (a) Committee on the Family Health and Medical Care PrOgralllDe. Policies will be established and supervised by a Committee on the Family Health and Medical Care Programme, reporting to the Administrative Board of the Harvard Medical School and the 'l'rustees of the Massachusetts General Hospital,and consisting of the Dean of the Harvard Medical School, the General Director of the Massachusetts General Hospital, the Professor of Medicine and Chief of the Medical Service, Harvard Medical School-Massa.chusetts General HOSpital, the Professor of Paediatrics and Chief of the Children's Medical Service, Harvard Medical School-Massachusetts General Hospital, the Professor of Psychiatry and Chief of the Psychiatric Service, Harvard Medical School-MassaChusetts General Hospital, the Professor of Obstetrics and Obstetrician-in-Chief, Harvard Medical School-Boston Lying-in Hospital, the Assistant Dean, Harvard Medical School, the Director of Nursing, Massachusetts General Hospital, the Director of Social Service, Massachusetts General Hospital, the Professor of Preventive Medicine, Ha.rva.rd Medical School. '!'his committee will me~t monthly. (b) Family Health Programme Staff. The Programme staff' will consist of:

(1) A physician who will be Chief of the Unit and Secretary of the Committee on Family Health and Medical Care Programme. He will be directly responsible for teaching and medical care, within pOlicies established by the Commi ttee, and for keeping the Comm1 ttee informed about the research programme. He will also serve as one of the family physicians to the families in the Programme, and will allocate responsibility to other physiCians in the Unit.

(2) Three half-to-fUll t~me physicians, representing medicine, paediatrics and psychiatry, who will co-operate in planning and operating the educational, medical care and research programmes. They will provide advice and guidance in their special fields, act as family physicians or consultants in the medical care programme, participate in stated staff meetings, take part in teaching the medical students, and conduct research. (,) Two residents, one in medicine and one in paediatrics, who will be responsible, under the direction of the Chief of the Unit, for providing for continuity of medical care to the families in the home, the out-patient department and the ward during the day. They will provide night coverage of the la-ogramme •

(4) A public-health nurse who will be responsible, in close co-operation with the medical social worker, for assuring follow-up of the families. She will be responsible for maintaining the family roster and will supervise and co-ordinate the programme mechanism under the direction of the Chief of the Unit. She will be designated by the Nursing Department of the Hospital, and will work closely •••

WPRO/SOC.PREV.MED./ll Page 4 will work closely with the Boston Visiting Nurse Associa1ion and the visiting nurses of the Boston City Health Department. She will be nursing consultant to the physicians in the service, teaching and research programmes, and to the medical social worker.

• .,.

(5) A medical social worker, designated by the Medical Social Service Department of the Hospital, who will be responsible for assuring proper utilization of community resources and for co-ordination of social services of the Hospital in meeting the needs of the families in the Service. She will be medical social consultant to the physicians in the Service, teaching and research programmes, and the public-health nurse. (6) An administrative assistant who, with advice and consultation from the medical statistician of the Department of Preventive Medicine, will assist in planning records and forms necessary for operation of the medical care programme and for collection and analysis of data for evaluating the medical care and educational programmes. The medical statistician will supervise preparation of protocols of experiment and analysis of research data.

(7) A secretary-receptionist and a clerk. The secretary-receptionist will handle telephone calls, greet family members and refer them to appropriate members of the Unit. She will also, with the assistance of the clerk, provide secretarial, filing and clerical services, including mechanical maintenance of patients' records. The Programme will be housed wi thin the Massachusetts General Hospital in an appropriate location which will facilitate the proper relationship with the Out-Patient Department, Admitting Office, Emergency Ward and Record Room. Adequate space will be assigned to the Unit to house its members and to provide conference rooms for student teaching. (c) Admission Procedure. To be eligible for admission to the Programme, a family must meet the following criteria: (1) residence in the geographic area served by the Programme; (2) has been receiving medical care from the Massachusetts General Hospital; (3) financial eligibility for the Out-Patient Department; (4) acceptance by the Programme and the family, after a conference at which the function of the Programme is explained. This conference will be attended by the Chief of the Unit, public-health nurse, medical social worker and other pertinent members of the Unit and representative family members. Before the family is formally admitted to the Programme, the physician and the public-health nurse will visit the family at home to meet the family as a unit and to make a first hand assessment of the family environment. The Chief of the Unit will make final decisions on admitting a family to the Programme • The following procedures will be conducted for each family member: (1) Complete medical history, to include a series of questions relating to environmental and economic aspects of medical care; (2) Medical social history; (3)

Complete •••

WPRO/SOC.P.REV.MED./ll Page 5 (:~)

Complete physical examination; Psychiatric evaluation;

(4)

(5) Laboratory tests and procedures, to include haemoglobin, leukocyte and differential count,s, urinalysis, stool examination, blood typing, serologic test for syphilis, 14 x 17 chest film and electrocardiogram. All this information will be recorded on specially prepl.red forms, designed for subsequent analysis. Each family member will receive a Family Health Programme card, with instructions for use of the Programme I s services printed on one side. The other side will provide space for typing pertinent identifying and medical data, including date of birth, blood type, date and nature of immunizations and the existence of sensitivities and any conditions which may lead to medical emergencies. (d) Follow-up Evaluations. Follow-up evaluations of all family members will be made at specified intervals. These will be spaced from one month to a year, depending upon state of health or illness of individual family members, their age and other pertinent factors. This last examination will be patterned on the admission procedure and will consist of those elements of history, physical examination and laboratory and other procedures useful in recognizing early disease or change in existing illnesses. (e) Routine Medical care. The medical care service will be the responsibility of the Chief of the Unit and may be delegated in whole or in part for specified times or for specified patients to another medical member of the unit, including the residents in medicine and paediatriCS. Insofar as possible, care will be provided through existing hospital services by referral, the staff member of the Family Health Programme aiding in maintaining continuity of supervision. Decision as to whether care should be provided in the hospital, out-patient department or the home will be based on the care required, the most effective personnel utilization, the convenience of the patient and the financial cost. All appointments for care in the hospital, out-patient department or home, other than emergencies, will be made through the Family Health Programme office. Service on request of a member of the family will be provided by one of two mechanisms:

(1) lay service, operating from 9 a.m. to 5 p.m. Monday through Friday, and 9 a.m. to 1 p.m. on Saturday: To facilitate communication between families and physicians, and to provide all services required, calls will be received by the Family Health Programme secretary-receptionist, who will handle all routine matters not involving medical or medical social decisions. Decisions as to services will be routinely referred to the public-health nurse, except in emergencies when they will be directed to the physiCian on duty •. The publichealth nurse, with the assistance of the family roster and the advice of the physician on duty, or when advisable by a home nursing visit by the district visiting nurse, will decide the time and place of the service. Emergency visits, admission to the hospital or home visits will be arranged by the public-health nurse after consultation with the Chief of the Unit or a designated •••

• WPRO/SOC.PREV.MED./II Page 6 designated representative, and service will be provided by the appropriate resident, medical, paediatriC, or psychiatric physician, or by the Chief of the Programme, as the case may demand, or the case may be referred to another hospital service, upon decision of anyone of these physicians. Appointments wi th ancillary personnel of hospital or community medical service and the outpatient department will be arranged by the public-health nurse. (2) Service at all other times, including nights, Sundays and holidays: .Calls in person or by telephone will be referred to the Emergency Ward. The clerk-in-charge will refer the call directly to the nurse-in-charge, at Whose desk the family roster will be located, and at the same time will page the Family Health Programme resident on duty. The residents in medicine and paediatrics, each assigned for a specified period to the Family Health Programme, will cover at night. They will accept initial responsibility for determining the need for, nature of, time and location of service to be provided. They will have direct responsibility for handling emergencies and for deferring care to day service. The Chief of the Programme or his designated representative will be available for consultation, in the same way as a visiting Physician on service on the hospital ward. The resident will be responsible for administrative arrangements involved in handling or in disposition of the patient, as for example in arranging for hospital admission. (f) Records. Each family member will have a unit record on file in the Record Room. To permit easy identification, a distinctive file cover will be used for these records. In-patient and out-patient service will be recorded in the customary way. Home services will be rec::>rded on form 267 (the "second sheet") either in writing in the event of a long report, or by using special forms to be pasted on to this sheet. Ancillary medical services provided by hospital or community personnel will be recorded on appropriate forms to be pasted into the unit record. The unit records will be handled in the usual way, except that they will be returned to the Record Rocm via the Family Health Programme office. This will make it possible for members of the unit to learn of services recommended or provided and therefore maintain better continuity of care and accounting control. The Family Health Programme secretary-receptionist will abstract information from the unit record to the special records in the Family Health Programme office. The special record in the office of the Family Health Programme will be a family roster and will include identifying information, unit record number and a current medical summary of each member of the family. The public-health nurse will be responsible f::>r assuring the current completeness of the records. A record system will also be devised to measure specific accomplisbments in the medical care and education programmes. A system of programme control will provide for periodic review, administrative evaluation and cost accounting of specific services.

.".

2•

THE EDUCATIONAL •••

•

WPRO!SOC.PREV.MED.!ll Page 7 2. THE EDUCATIONAL PROGRAMME •

After the medical care progr-amme is established, the educational experiment of training medical students in a family receiving complete medical care will be begun. Each student will be supervised by one of the family physicians in the unit --- his instructor. Families will be selected for assignment to students from the total pool of families in the Family Health Programme. Priority of assignment will be determined by teaching opportunities presented by the families and their willingness to accept a "doctor in training". First priority will be given to families in which the mother is pregnant •. During the period of his undergr-aduate medical education, the student will closely observe the course of pregnancy, be present at the delivery and follow the physical and mental development of the newborn. This changing situation would justify repeated visits by the student and prOvide a continual teaching situation which will be supplemented by a programme of preventive health guidance and complete medical care for all members of the family. Second priority will be given to families in which a member has a chronic illness. This would be a unique opportunity for a student to study the natural history of long-term illness, would justify frequent visits and provide a continual teaching situation. . After assignment of the student to his family, he will meet the family as its "doctor in training". As the student's experience and capabilities gr-ow, his supervised responsibility will increase correspondingly. It will be the function of the student after assignment to: (1) complete review of hospital record or any other available source . of information on all members of the family; (2) confer by appointment with any medical and health personnel who have had major responsibility for health problems of the family. These my include members of the visiting and house staffs, medical social workers, public-health nurses and other health service personnel of the hospital and of accessible community agencies;

(3)

review the family history with the family physician;

(4) be introduced to the family by the family physician as its "doctor in training" and make an appointment for a home visit alone with the family; (5) make initial visit alone for establishing rapport and for up-todate review of the health record of the family; (6) make subsequent visits at regular intervals and at times when health emergencies arise, depending upon the student's other academic responsibi11 ties. These visits will be made alone or with the family physician or other consultant (medical, paediatric, psychiatric or surgical), as determined by the instructor. (7) make written report to the i'amily Health Progr-amme as soon as possible following each visit to the family; (8) present to •••

. WPRO/SOC.PREV .MED./ll Page 8

. ••

(8) present to his entire class once each academic year an interesting family health problem at a clinic on complete medical care to be organized under the supervision of the instructor. Participants in the clinic will include representatives of all relevant medical specialties, ancillary medical personnel and members of the university departments and community agencies related to the health problem under discussion. During his third and fourth years he will accept exactly the same kind of supervised medical responsibility for the family in the home and hospital as he does now in the out-patient and in-patient services of the hospital. Because experienced teachers have seen both advantages and disadvantages inherent in beginning in the first and in the third years, it seemed wise to the Faculty to start with both groups. It is proposed that in the first year of operation of the educational programme, equal numbers of first and third year students be assigned and that a method of evaluation be established to determine which is better. In the second year of the project, an additional group of first and third year students will be assigned. This process will be continued if it is deemed advisable to admit both first and third year students to the experiment. A first year student would have the advantage to continuous follow-up of a family for four years, with gradually increasing responsibility for its medical care. During the first two years, his role would be that of an observer of a complete medical care programme in action in a family of whose needs he will gradually become aware. His actual experience in the application of medical knowledge would begin in the second half of the second year during his course in physical diagnosis, when he could perform physical examination of members of the family under the immediate supervision of the instructor. On the other hand, assignment of students at the beginning of the third year instead of the first year would have the advantage of bringing the student into the service at a time when he has medical competence to accept minimal supervised responsibility for the care of the patients. It would avoid the recognized danger of a student in his first or second year accepting medical responsibility without training. After a few years of experience it should be possible to determine the optimal time for student assignment. When a definite decision regarding optimal time for student assignment will have been made, a group of students will be allocated each year until the termination of the experiment at the end of five years. At first students will be asked to volunteer, and of that group those with higtJ.est class standing will be selected. If this experiment is successful in its first two years of operation, the suitability of extending this teaching method to the entire class will be studied by assigning a representative sample of students to the Family Health Programme. At the end of five years it should be possible to present the results of this experiment to the Faculty to determine whether this method of teaching should be extended to the entire student body •

• 3. POST-GRADUATE

WPRO/SOC.PREV.MED./ll Page 9

POST-GRADUATE EDUCATION

The Family Health Programme should be useful in developing close relationships with the family physicians practicing in the geographic area of the programme. Every effort will be made to develop a service in the Out-Patient Department in which the local physicians will be invited to take part and for which they will be granted appropriate hospital appointments. It is hoped that these physicians will visit their patients admitted to the wards of the Hoepi tal for the purpose of maintaining continuity of medical care, and will contribute progress notes to the clinical record. Assistance from the Family Health Programme will be available in solving health problems of families under their care in the same geographic area. They will be welcomed at the teaching exercises. After the undergraduate medical education programme is in operation1 a graduate programme for the training of family physicians, including house officer training, will be inaugurated. This educational programme and co-operative arrangements with the private physicians in practice in the community served by the Massachusetts General Hospital should eventually provide better continuity of care than is possible at the present time.

•

RESEARCH

A group of families, under close medical supervision by a well co-ordinated group of physicians, basic SCientists, SOCiologists, and members of ancillary professional groups, organized for the purpose of tea.ching medical students complete medical care, will provide an excellent epidemiological laboratory for the study of problems related to the evolution of disease in well populations including those related to physical and mental growth and deVelopment. Ylhen the medical care teaching programme is functioning smoothly, representatives of each of the specialties in the medical care unit, in co-operation with members of Harvard University in the fields of sociology, anthropology, biostatistics, epidemiology, experimental psychology and other appropriate disciplines will plan a research programme and prepare definite protocols of experiment for specific studies which can best be carried out wi thin the framework of the medical care unit. Funds will be sought as needed for research planning. Additional funds will be sought for specific studies after their approval by the Committee.

. WRLD HEAL'lH ORGANIZA TION REGIONAL OFFICE FOR THE WES'lERN PACIFIC WPRO/SOO.PREV~./12

S'IUDY GROUP ON SOOIAL

AND HtEvENTlVE

MEDICINE

.3 October 1957 ORIGINAL a ENGLISH

Manila, Philippines 1.6-29 October 1957

A PRORlSAL FOR 'JHE TEACHING OF PUBLIC HEALTH & OOCIAL MEDICINE

K. J. Mann, M. D.*

.. 1 2 :mmonUCTION

CON'lENl'S

Page 1 1

mE ESTABLISJtfENT OF EFFECTIVE PRECLINICAL AND CLINICAL TEA.CH:mG FIE~

'!HE WIDENING OF THE 800m OF EXIST:mG DEPAR'lMENTB; AND THE ESTABLISIMENT OF NEW ONE:), FOR THE 'IEACH:mG OF PUBLIC HEALTH AND SOCIAL MEDICINE '!HE CREATION OF DEPAR'.IMENTS OF ADMINISTRATION OF MEDICAL CARE, BIOSTATISTICS AND MEDICAL EDUCATION, FOR OO'lH SERVICE AND TEACHIID

4 ~

5 6

THE REDEFINED PRECLINICAL, CLINICAL AND .kllHNISTRATIVE DEPARTMENTS AS A TEACHlID UNIT THE CREU'ION OF A DEPARDmNT OF PUBLIC HEiJ..'lH AI!(INISTRATION OUTLINE OF TRiUNING IN PUBLIC HFALTH i.ND SOOIAL MEDICINE '!HE DIVISION OF PUBLIC HEALTH AND SOCIAL MEDICINE AND ITS USE FOR UNDERGRiUlUATE mCHING mE DPISION (F PUBLIC HFJ.LTH AND SOCIAL MEDICINE AND ITS USE FOR POSTGRADUA'IE TRAINING SUMH:i.RY

..3

8 9 10

5 5 6

*Director General, HadassahMedical Organization '!his paper was not prepared expressly for the Study Group but is submitted ~or information o~ the participants •

•

WPRO/SOC.PREV.MED./12 Page 1

INTRODUCTION

Health is that state of balance between the internal and external environment of Man, which results in his phYSical, mental and social wellbeing. In formulating aims of health care and education, all conponents of Man's internal and external enviro runent should be taken into account and facilities provided for the organization of medical care and its administration in such a way as to cover all too various fields that have a bearing on the health of Man. Similarly their Significance should be iniJarted to undergraduate and postgraduate students of medicine, nursing and other health workers so that they learn to view Man not :;,nly as an individual but also as a rember of a family and of a larger social group; not only as a physical entity but also as the product of emotional stresses, anxieties, fatigues and pleasures; working and living within an environment that surrounds him not only with physical amenities and obstacles, but also with emotional and social stresses and fulfilments. 2. 'IHE ESTABLISIlffiNT OF EFFECTIVE PRECLINICAL AND CLINICAL

...

TEACHING FIELDS In order to 1nplement this wider approach to health, there is still need for radical changes to be introduced into the basic training of our health workers in their preclinical years of study, as well as into their clinical field of work.

It is no longer sufficient to teach our undergraduates the basic sciences as the foumation on which to build their clinical studies. '!he social sciences, such as economics, sociology, anthropology, psychology, are as iniJortant a part of that foundation as are the exact sciences. A balance should therefore be struck between the teaching of the exact and the social sciences so that the student appreciates fully not only tm importance of physiology, biochemistr,r, bacteriology, etc., but also of economics, sociology, psychology, etc. as vital instruments in his understanding of Man and his environment. Neither is it sufficient to impart clinical knowledge to our students within the hospital frame'l«lrk only. This teaching has to be supplemented by clinical training within the colllllunity itself, lh ere the student can view Man not only as an individual but also as a member of a family and a cOllllllunity; not only as a physical al tity but also as a psychological and social teing; mere he may appreciate the role of environment, physical or social, as a factor in health. The correction of these deficiencies in our preclinical teaching is in the hands of the Board of Management of the Medical School, while those in the clinical years are in the hands of Hadassah Medical Organization which haS designated for that purpose the mole region of Jerusalem and the Corridor as its field of clinical training. Within this region it has established an overall administration for the various clinical facilities provided for the population of SOIOO 200,000. These facilities include not only the traditional UniverSity Hospita1~ with all its diagnostic and therapeutic departments, but also services within the cOIllllDJ.nity to the IOOther, infant and toddler through l-.other and Child centers, and to the school-child 1Il d

•••

WPOO/soc.PRE.m:D./12 Page 2 school-child and university students through its Department of Student Health. In addition it now includes the new pioneering services geared to the family add Community Health, with its Neighborhood Family and Communiw Health Centers of Bet Ma~ilJ Talpiot, Katamon C, Kastel and Hartuv; and secondly the health service to the Hadassah staff which will form the nucleus of a new Department of Occupational Health. I t is this clinical work in the Community that will bring the undergraduate and graduate medical ani nursing student to appreciate the importance of the phySical, biological and social environnent to the health of the people who live within it. It is these new deparlnent..s of Family and:;ommunity Health, Student Health and Occupational Health, that will enable the student to view his p2. tients against the background of their families and communities; that will ena 1:iI.e him to follow them through from the primary social unit - thu family - to the secondary ones in school and at work.

Through these community services the framework for teaching nursesJ phySicians and other health workers has been immensely widened beyond what is traditionally prov:1ded in a teaching hospital. It enables the student to appreciate individual health and pathology, as well as family, communi4Y and emrirollIOOntal health and pathology, against the appropriate physical J emotional and SOCiological background. It enables the student to understand the special medical problems in the homes, schools and places of work and his role in the promotion of health and prevention of disease J in addition to the traditional tasks of diagnosis and therapy.

3. THE WIDENING OF ruE SCX>PE OF EXISTING DEPARHNTS, AND THE ESTABLISHMENT OF NEW ONES, FUR THE TEACHING OF PUBLIC HEALTH ;.ND SOCIAL l"lIDICINE However, the Hadassah Medical Organization's clinical instrument for care and teaching is still far from complete. There is a need to strengthen some existing departments, especially those within the community; there is also a clear necessity to widen the scope of the existing clinical departments of the University Hospital so as to include under their aegis not only the diagnosis of complex m.;)dical problans of too individual, but also the solution of complex problems in their specialties which arise in connection with the promotion of health, the prevention of disease and its diagnosis in groups and communities within the region of Jerusalem and the Corridor. It is furthar essential to establish in the clinical field new departnents to 00 concerned primarily with the promotion of health and prevention of disease in individuals, groups and communities, to complement the traditional hospital departments that are main~ concerned with diagnosiS and therapy. Some of these departments, such as Bnvironmental Hygiene, Epidemiology and Social Medicine, now exist within the area of our preclinical facilities, and their teaching functions are carried out main13" in the preclinical years. The fUnctions of these departments should be extended to include a clinical responsibility in the region served Qy Hadassah Medical Organization. In that service section of their work they would be responsible to the •••

WPRO/SOC.PREV.MFIJ.,1J.2 Page 3 responsible to the HJl.O. administration, which would place at their disposal the clinical field of the whole region am its people, with its hospital and community healthy services, not only for service, but also as an instrument for clinical teaching and research. Certain other defSrtments such as Growth & Development., Health Education, etc., would have to be created to help in the planning and inplementation of medical services for the region as well as to carry an academic load of teaching and research in these subjects_ The introduction of these additional departments and the widening of the scope of our existing clinical departments will convert the highly specialized clinical instrument we call a "hospital- into a comprehensive "Medical Center", equipped to handle not on],y diagnostiC problems in individuals, but also problems in promotion of health and prevention of disease, as well as diagnosis of physical, emotional and sociological pathology in groups and conmn.mi.ties.

'lHE CJ&TION OF DEPAR'lMENTS OF AIMINISTRATION OF MEDICAL CARE, BIOSTATISTICS AND MEDICAL EDUCATION, FOR oom SERVICE AID TEACHING

The planning am creation of an effective clinical instrument for medical care, teaching and research has been in progress for the last few years and it is bound to continue for many more years so as to keep abreast of modern medical concepts. Up till IXIW this burden of planning and its implementation has been carried by the Hadassah Medical Organization administration by virtue of its day to day responsibilities to the population of. Jerusalem and the Corridor. The time is now ripe for the creation of an academic department of The j,dministration of Medical Care so that the people m.o have the field responsibility of planning and adIIinistering the regional medical services supplies by H.M.O. should also have responsibili~ to thG Faculty, and hence to teachirg and research in this important field. It is quite obvious that this overall administration cannot function scientifically without. an efficient Department of Biostatistics which should supp~ the administration and the various community am Medical Center departments with vital statistics of population, environroont, health and disease in the region under its care. Neither can it function effectively wi. thou\; a Department of Medical Education to provide the administration VJi. th the norms and the training requirelOOnts for the various health workers to service a region with a population of close to a quarter of a million people. These tw departments, which do not now exist, should be established with dual functions: firstJ¥ for service, ld th a responsibility to the H.M.O. administration, and, secorxi~, for teaching and research, with a direct responsibility to the Faculty.

THE REDEFINED PRECLINICAL, CLINICt.L lIND AI1UNISTRATIVE DEPAR'lMENTS AS A lEACHING UNIT

When the totn.l".p;t.anning and implementat:ion of the regional administration the medical services within the community, and the speciamed dcpartlOOnts within the Medical center are all complete, the student will have an excellBnt instrtml3nt for studying the population for whom he will have an excellent ••

I -~

WPRO/SOC.PREV.MED./12 Page 4 have an excellent instr1llOOnt for studying the popula tion for whom he will have to care; their number, their distribution according to age, sex and ethnic groups, their morbidity rate in various ages~ their mortality rates and its causes, the incidence of chronic disease, old age, earning capacity, nutritional state, etc. He will also come to appreciate the importanoo of the physical" biological and sociological environmant in which this population resides arx:l. frem which it draws its livelihood. He will learn What medical services ought ideally to be provided for this population, and mat is provided for them in pra= tice. He will fUrther gain an insight into how the region and its medical services are administered, and the relation of these services to local .~governmantal authorities. He will COIlE to appreciate his own place in this total structure and the place of medical education and the training of physicians, nurses and other health workers, so as to be able to give effective health services to the population.

'!HE CRE["TION OF 1... DEPAR'lMENT OF PUBLIC HEl~L'ffi AllHNISTRi. TION

However, even with this enlarged teaching field, the overall national problems of health and the national administra tion of hoalth will still elude the student. This lacuna in his comprehensive understanding of health am its administration should be filled by members of the staff of the Ministry of Health" who are engaged in this field of W?rk. They should be established as an academic department of Public Health "dministration responsible to the Minister of Health as regards its services to the nation, and to the medical facult,y as regards its teaching and research functions in problems of health and health administration on a national level.

7. OUTLINE OF TRi.INING IN PUBLIC HEiiLTH l.ND SOCIl.L MEDICINE '!hus existing structure of the Hadassah Medical Organization, services and administration" alrea;,y provides the basis of an excellent teaching medium in Public Health and Social Medicine for undergraduate and postgraduate stUdents of Medicine and Nursing. This instrUIOOnt for teaching Public Health arx:l. Social Medicine w:>uld become incomparably IOOre modern and efficient i f the above recoImlendations are implemented. 'Ihe student w:>uld then be able, in his preclinical Years, to l1:V the foundation for his future clinical training in Public Health and Social Medicine through tho s:Illdy of the exact and social sciences; this would be complemented in the 3rd and 4th years by teaching in the departments of Environmental Hygiene, Social Medicine, Biostatistics and Epidemiology. He would thus be provided with all the essential tools for his stuQy and understanding of Man's normal internal and rocternal environment, whether piVsical, psychological or SOCiological. With this foundation the s tudent ~uld proceed, in his 5th year, to a national field of study in the departllEnt of Public Health ,",dministration, and would follow it up on the regional level in the department of 1.dministratioD of Medical Cam - spending about one m::>nth in each of these departments. Once national and ••

WPRO/SOC • PRE V.MED./12 Page

Once national and regional health reeds, problems and adminiBtration are grasped by the student he will be able to complete his Wlderstanding of group and community health" of physical" emotional and social pathology during his training in the clinical departments" both in the COllllllUOity, such as the departments of Family Health, Student Health, Occupational Health, etc., as well as in the Medical Center in such departments as Pediatrics, Obstetrics, Mental Healt~ Growth & Development" Health Education, etc. This training in the wider aspects of health would initially have to be undertaken l:!Y physicians especially trained in the public health and social medical aspects of their specialties, with the intention that ibis approach would eventuall,y permeate the institution and find exp ression in the teaching of each and every member of the departments. During the block periods in the department of Public Health i.dministration and l.dministra tion of Medical .~are, as well as during the students' continuous training wi thin the clinical departments" it is of course essential that the Departments of Environmntal Hygiene, Epidemiology, Social M0dicine and Biostatistics should continue to contribute, as in the preclinical years, to the teaching of group" comnnmity and environmental pathology. fl.}; 0 in the course of the block periods allotted to the lJepartmnts of Public Health ••dministration & .,dminiBtration of Medical Care, the Department of Medical Education will present its program for the training of the various health workers required for carrying out the nation's health services.

'IRE DIVISION OF PUBLIC HEl..LTH & SOCI1;.1 MWICINE 1'15 USE FOR UNDERGR1JJU1~TE TEI~(]nNG

1I.ND

. All the departments - administrative" preclinical and clinical, in community and in mdical center - which partake in the teaching of public health and social medicine, should together form a Division of Public Health and Social Medicine whose chairman muld in the first instance. be respomible for the exact planning of the Division's teaching curriculum and its implementation. In consultation with his colleagues in the Divisio n, he would submit to the Faculty a detailed curriculum for the twomnth block period that the students wlll be spending in the Division of Public Health and Social Medicire, as well as for the special teaching responsibilities in this field of the various clinical departments. The Chairman WJuld 1::e responsible to the Dean for the implementation of this program throughout the preclinical and clinical years.

lHE DIVISION OF PUBLIC HEJ.LTH & SOCIAL MEDICINE AND ITS USE FOR roSTGRADUATE TR1JNING

It is clear that such a Division of Public Health and Social Medicine and its component departments could, with modification, form an effective instrument not only for undergraduate but also for postgraduate training of physicians" nurses and other medical arxl. non-medical specialists, whose main aim is the health of Han and of the environmnt in which he lives.

10.

S T.IHMi.RY ••

WPRO/SOC .PREV.MED ./12 Page 6 10. SltlMARy

In oroer to establish an effective instrument for the teaching of undergraduate and postgraduate Public Health and Social Medicine, it is necessary for certain modifications to re introduced into our preclinical and clinical instrument of service and teaching. 1) The training of our sttrlerrts in their preclinical years should be widened so as to ioolude the social SCiences, such as psychology, sociology, anthropology and economics, as well as the exact sciences. 2) The existing clinical departments within the conrnunity should be strengthened so that they can fulfil their academic functions in addition to their service responsibilities. A.

The scope of the existing clinical departlOOrrts in the hospital should be widened in such a way as to enable them to be used rot only for help for individual cases, but also for group a1d cOllDllunity problems within their speCialty.

There is a need to establish new departments within the Medical Center such as Growth & Development, Health Education, etc., which could undertake the functions of health promotion am prevention of diseases in individuals, groups, and communi ties.

It is essential to }rovide the existing departments of Environroontal HYgiene, Epidemiology and Social Medicine with responsibility not only in the academic field but also in the clinical field of service within Hadassah's regional responsibility for IOOdical care.

In addition, there is a need to establish four rew departments that are essential to the overall planning and implelOOntation of health services: Public Health Administration, Administration of Medical Care, Medical Education and Biostatistics. These departments must have service as well as academic respo rsibilities. All these departnents - preclinical, clinical. and administrative will form a Division of Public Health and Social Medicine which, through its chairman, will submit to the Faculty a detailed curriculum for the ccmprehensi'le training of undergraduate ani postgraduate students in these areas. The various departments compnslng the Division of Public Health and Social Medicine will be using their respective fields of service, both clinical and administrative, both in the community and in the medical center, as tools by which their teaching responsibilities may be implemented. 7)

Jerusalem, February 1957 ~

WORLD HEALTH ORGANrlATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

REGIONAL OFFICE FOR THE WESTERN PACIFIC

WFRO/SOC.P.REV.MED./13

9 October 1957 ORIGINAL: ENGLISH

Manila, Philippines

16-29 October 1957

THE PHYSICIAN IN HEALTH EDUCATION

by George Ro'sen, M.D., Ph.D.*

Proressor or Health Education, School or Public Health and Administrative Medicine, Columbia University

This paper was not prepared expressly for the Study Groop but is submitted ror rererence or the participants.

· ,

WPRO!soc.PREV.MED.!13 Pagel Available evidence indicates that fr~ the earliest periods of human history man has wanted to know how to stay well, how to avMd disease, and how to deal with sickness and its consequences. Whether medicine man, priest or physician, the healer has always been regarded as an important source of information and guidance in such matters. The way in which he has performed this function at different historical periods and in various places has been governed by a number of factors. Among these may be mentioned the social status of the physician and of his patient, the level of medical and scientific knowledge, the state of the communication arts, the levels of education and literacy in the community with which the physician is concerned, and the mode of organization of medical care. Greek medicine provides a case in point. Throughout its history, Greek medicine was never exclusively curative. From its beginnings the preservation of "health seemed the more important task and a great deal of thought was given to problems of hygiene. Health to the Greek physician was a condition in which the various forces or elements constituting the human body were perfectly balanced. Disturbed equilibrium resulted in disease. It was important, therefore, to maintain a mode of life in which such disturbances might be reduced to a minimum. The ideal mode of life, according to the physicians, was one in whiCh nutrition and excretion, exercise and rest were perfectly balanced. In addition, for each individual, account had to be taken of age, sex, constitution and the seasons. In essence, one's whole life had to be organized for this purpose. Very few people, however, could afford to lead such a life. This was .a regime for a. small upper class leading a life of leisure, a c~ss supported by a slave economy. It was an aristocratic hygiene. The mass of the people, said the writer of the HippocratiC book , On Diet '~y necessity must lead a haphazard life and ••• neglecting all, cannot take care of their health". This attitude is reflected in the lack of attention paid to the health problems of those who had to work for a living. Hlysicians who wrote works on hygiene, e.g. Diodes of Karystos (fourth century, B.C.) addressed them to members of the upper class., Health ~ducation and personal hygiene were areas to which the Middle Ages also made important contributions. Mediaeval man was far more occupied with the care of his body than one might imagine. This interest gave rise to a whole literature on the preservation of health derived from classical sources. As a rule, the mediaeval treatise on hygiene was addressed to a person ,of high rank, advising him how to live in order to remain healthy. From the twelfth to the fifteenth centuries a large number of such books were written in Latin or in various vernaculars. The best known work of this type is undoubtedly the Regimen sanitatis Salernitamum (The Salerniton Regimen of Health) which probably originated during the twelfth century, and was published in England, Italy and Germany as late as the middle of the tenth century. This didactic medical pOem, and its literary'successors, the popular health books and alma~s which flooded the European countries soon after the beginning of printing, treated every detail and indicated how to care for every part of the body. With the growth of Cities, the rise of a literate middle class, and the invention of printing, such writings increased in d1vers1ty and number from the sixteen century onward. They dealt wifuthe hygiene of pregnancy, the care of infants and children, what to do in time of pestilence, the achievement of longevity, as well as with other aspects of health. Many were written by phYSicians, •••

(

WPRO/soc.PREV.MED./13 Page

-. r

by physicians, but some were prepared by laymen-priests, schoolmasters and others. This trend was also fostered by the appearance of new diseases, such as syphilis. This trend progressed still fUrther in the nineteenth century. The didactic impulse of the enlightenment expressed itself in an endeavour to enlighten the people in matters of health and hygiene. This health education movement was international in scope, and while it was adapted to suit local circumstances,·its central characteristics were more or less the same in all countries - everywhere the same appeal to reason coupled with a belief in progress and perfectibility. Illustrative of the many books and pamphlets written to further health education are S. A. Tissot's Avis au peuple sur sa sante, which appeared in 1762, went through ten French editions in six years, and was translated into several languages, and B. C. Faust I s Gesundheitskatechismus, published in 1794. The latter was so popular that 150 000 were sold, and it Was even translated into Latvia. Physicians were extremely active in this movement. FOr the most part, however, the advocates of health education addressed themselves to the upper and middle classes, not to the peasants·and artisans. Nevertheless, slowly but surely the spread of health knowledge began to ai':f'ect the working masses in town and country. The effects of the industrial revolution in the nineteenth century, the extension of schooling and literacy among the factory workers and their families, and the campaigns for sanitary reform in Great Britain, Germany and France and the United State~ - all left their imprint on the lower social classes. Pamphlets and leaflets were dist~buted, lectures were given, campaigns were organized, and in all these activities in community health education a certain number of physicians were active. Endeavours to impart health information and guidance continued through the nineteenth century and into the twentieth century more or less along the lines described above. When health departments were established, they began to -develop this function. Furthermore, around the turn of the century, in carrying out new programmes concerned with prevention of communicable diseases, improvement of maternal and child health, school health, tuberculosis control and related problems, health agencies found themselves engaging in expanding programmes of education. To promote health and prevent • disease, it was necessary to combat ignorance. This emphasis, characteriS"tic of the period which began toward the end of the nineteenth century, eventually led to a recognition of health education as a major function in the community health programme. The function of the physician in providing health information and guidance was variously affected by these developments and others that have become more prominent in our time.- For one thing, the last thirty-odd years have seen the introduction of important technical means of mass communication; radio and television. Concurrently the newspaper and the magazine developed forms calculated to attract the mass audience that became available as literacy spread in the industrialized and economically advanced countries. As a result the physician is to an increaSing degree confronted, in countries like the United States, Great Britain, and others on a similar level of development, with patients equipped with varying amounts of health information, and primed to ask for more. Finally, inalch countries because of voluntary pre-payment or tax-supported •••

" "

II "

WPRO/SOC.PREV.MED./13 Page 3 or tax-supported schemes, medica1 care provided by physicians is availAble to more people than ever before. Physicians are thus brought to an increasing degree in contact with patients from various social l~vels. Thus, the physician is being compelled by force of circumstances to deal with prob1ems of health teaching within a socia1 framework of greater comp1exity. In the Ught of these trends, how can the physician best fulfil his ancient and enduring function of teaching, guiding and counselling in health matters? First of all, it must be pointed out that individual oral instruction is more effective with most patients than other means. Flesh and blood contact and the opportunity to question and answer back carry the greatest conviction. And most physicians continue to carry out this function with greater or lesser degrees of awareness. Dowling & Shakow, in 1952 (J .A.M.A., June 1952), surveyed a group of general practitioners and internists in Washington, D.C., and showed that these physicians devoted approximately one-fifth to one-half their time in informing and guiding patients and their families in health matters. In paediatrics and obstetrics (well-child care and antepartum care) this aspect of practice is even more prominent. While many physicians are still like M. Jourdain before he discovered that he had been speaking prose all his life, others have recognized that the teaching of patients can be made more efficient and more effective if carried out in an organized manner. Such physicians do no begrudge the patients' natural curiosity and anxiety, and have 1earned that an "educated"patient more often than not is a satisfied patient. Naturally, the means for achieving such an objective wi11 vary with the type of practice, the awareness of the physician, his personality, and the populAtion group with which he is dealing. In the United States, a number of physicians have learned to supplement face-to-face contacts with printed materials. This is particularly true of paediatrid ens and obstetricians, and to a lesser degree of other practitioners (see for example William B. Schafer: Your Office Needs a Lending Library, Medical Economics, May 1957). A few physicians have gone a step further and have arranged ciaSSes for their patients. A group of four obstetricians in Seattle, Washington, have found that classes for expectant parents, which they conduct, result in informed patients and less harried obstetricians. Every Wednesday night during ten months of the year a score or more pregnant women gather in the obstetricians' reception room. They bring their husbands too, and they spend the time finding out what it is like to have a baby. Each ;'''course'' lasts six sessions, and then another group starts. Informal lectures, question and anS1,er periods, films are used. (See Hugh C. Sherwood: How to Educate Patients to Parenthood, Medical EconomiCS, April, 1957.) , However, no matter how well-intentioned the physician may be, in practice he usually comes in contact chiefly with sick people and their families. Rarely does he have an opportunity to teach well people, especially when he is engaged in fee-for-service solo practice. Certain recent developments in the organization of medical care have made it possible for practising physicians to carry on health education with people outside the office. For example, the Soviet Union has developed what is probably the most completely integrated system of health education. Within this ~'~~m physicians carry on hea~th education among well people as a regulAr part of their work (see J. Burton: Integrated Health Education in the Soviet Union, Health Education Journal, 14, 37-53, 1956). In the United •••

. •

WPRO/SOC.PREV.MED./13 Page

In the United States, the incorporation of health education in a comprehensive programme of medical care has been carried farthest by the pre-paid group practice pJJm.s and union health programmes. This trend has been most fully developed in the health education programme of the Health Insurance Plan of Greater New York. The HeaJ.th Insurance Plan (HIP) is a community-sponsored, voluntary medical care plan which provides comprehensive medical care (preventive, diagnOstiC, curative) to over 500 000 people through 32 affiliated groups of physicians. HeaJ.th education is considered a part of preventive medical care. ~wv basic premises underlie the educational programme, which is developed and administered through a Division of Preventive Medicine and Health Education. In the first place, it is not enough simply to provide oo'mprehensive medical care on a prepaid basis. Effective preventive care requiresnot only the removal of financial barriers between patient and physician and the provision of adequate facilities, but equally a well-organized programme of heaJ.th guidance. Members of the Plan, whether well or ill, must receive information and acquire understanding concerning health and illness. They should also learn to recognize their health needs and how best to meet these needs through the services provided by the affiliated medical groups. Secondly, pre-paid group practice offers an unique opportunity to develop the traditional doctor-patient relationship with a physician as a member of a medical team. The large majority of the people who jOin HIP are accustomed to a relationship with an individual practitioner and must be guided and assisted to establish a similar relationship within the framework of group medical practice. It is unrealistic to separate knowledge about disease or wise health habits from Understanding and efficient use of medical services. The programme seeks to bring together the persons who render medical care and those who receive it. Meetings, discussion gl'Oupsand quarterly health bulletins are the major instruments used in this effort. The Division of Preventive Medicine and Health Education has a staff of health educators who work with the physicians of the groups. In general, meetings provide guidance in some specific area - health care, mental health - and enable subscribers to understand better what medical group practice is and how it works. Meetings have covered such subjects as: chronic illness, parent-child relationships, new developments in medicine, eye care, human reproduction, health problems of· women, underweight, overweight and modern surgery. Another aspect has been the de~elopment of small discussion groups concerned with specific age categories and health problems. One series involved pre-adolescent girls and their mothers, another was devoted to patients with allergies, still another was conducted with parents of infants under six months of age. Several medical groups have conducted classes for expectant parents. These activities are conducted by the physicians who provide the medical care. However, physicians who begin to explore the possibilities and potentialities of health education are in most instances embarking on a complex, and for most medical men, unchartered operation. They need reassurance, assistance and guidance. The staff of the Division works with the physicians, suggesting certain approaches and assisting them to improve their teaching skills. As the educational activities are intended to meet the expressed needs of the subscribers and physicians involved, various means are used to discover such needs. These include conferences with physicians, the use of questionnaires for members •••

"',

WPRO/SOC.P.REV.MED./13 Page 5 for members of the plan, questions and comments at meetinge, the development of patient-physician committees to provide continuity in these activities, as well as an awareness of health problems in the community at large. The health educators of the Division help the medical groups to plan their meetings and discussion groups. They help the groups to obtain and evaluate the films, pamphlets and other resources that my be needed. Finally, they report on the. strengths and weaknesses of the meetings and make suggestions for their improvement as well as for the development of the entire educational programme. The medical groups sponsor quarterly health education bulletins w.hich provide informtion on health topics and group administrative mtters. Groups are encouraged and helped to use such educational aids as exhibits, pamphlets and' leaflets. Special meetings are arranged as needed to orient new bodies of members. This programme developed by the Health Insurance Plan and its affiliated medical groups shows What can be done on a planned basis. From the above, it is<Dvious that physicians can engage in health education under· a variety of circumstances - in the office, in the hospital, in a health eentre, in a pre-paid medical care plan. For example there is a slowly growing recognition of the need for education in hospitals (see editorial: Relatives in Hospital, Lancet, 11 May 1957, pp. 975-976). For such a trend to develop fully certain prerequisites are necessary. In the first place, the physician must be alert to the teaching possibilities in the closer doctor-patient relationship. For busy physicians in practice this may not be easy, but that ways can be found to handle the time_problem is indicated by the examples cited above. It is certainly ~asier when physicians are organized in group practice. For this purpose, a hospital can more easily serve as a centre ·for a community or small group educational programme. Several hospitals in the United States have undertaken such activities. Medical societies have also organized public forums where panels of physicians answer questioDs put to them on specific topics. -In general, it is probably true that there has been no systemtic attempt to discover the best methods for teaching in the practice of medicine. The physician, in no matter what situation he operates, should have an awareness of the patient I s need for guidance. Furthermore, he should be aware of the influence of cultural factors in learning. Very often, even w.hen a physician takes the time to explain something to a patient, his language my not be understood (see, for example, F. C. Redlich: The Patient's Language, Yale J. Bio!. Med. 1945, 17, 427-453). Equally important is the qlestion of social status and its impact on the doctor-patient relationship. This element may significantly affect the role of the physician as a teacher and of the patient as a learner. Finally, the phYSician should have some awareness of how learning occurs. For example, that it is not enough simply to talk at people, that one must have some idea of where the learner stands and what motivates him to learn, and how to relate the physician's own needs to the learning process, and other related mtters. Obviously this is a big order and may be very hard to carry out with ph)"sicians in solo practice who can be reached only with difficulty. It is certainly more logical to begin with the medical student and the young doctor in the hopsital. Every medical student should be taught how to talk with people, with his patients, and the members of their families, and how in so doing to get them to talk to him. A programme of this type has been carried on for almost •••

WFRO/SOC.PREV.MED./13 Page 6 on for almost a decade now at the State University Medical School in Brooklyn, New York, under the guidance of Irving S. Shapiro. Such a programme could then be reinforced in the hospital, if the environment were favourable. Hospitals in the United States have begun to examine the patient satisfaction and what patients like and do not like about hospital routines. Endeavours of tbls type might under proper leadership be developed into full-scale educational programmes involving physicians and other hospital personnel. Any approach to this problem must, obViously, take into account that the medical student, the hospital doctor and the physician in practice all have their own needs of which account must be taken. In any event, none of this will matter as -long as the physician looks at the patient as an object, a case, and not as a person, a human being of flesh and blood. To a certain degree, the physician may be helped in this matter by other personnel, nurses, social workers, health educators, and so forth. S\lllIIIIS.ry (1) Physicians are carrying on health education, often without real awareness of what they are doing and with inappropriate methods. (2) A minority of physicians have recognized the significance of health education in terms of their needs and are endeavouring to do something about it.

(3) All physicians could do a better job i f they were aware of what they are doing. (4) Physicians can be reached and "taught about health education within an organizational framework, e.g. a medical care plan, or a clinic, or a hospital.

(5) It is probably best to emphasize the need for the educational approach in the training of the medical student. (6) Research is needed on the best way to carry on health education in medical practice. (7) In addition to arousing a~eness, physicians, especially medical students, should be taught how learning occurs, the impact of socio-cultural influences, and the like.

(8) Existing professional agencies, such as medical societies, may be brought into health education activities. (9) The significance of mass media of communication (press, radiO, television) should be taken into account in health education work by physicians, but personal contact and influence are still the most effective teaching tools. (10) Obviously, the physician must be supported by other professionals, (nurses, health educators, social workers).

WORLD HEALTH ORGANIZATION

REG IONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./14

AND

STUDY GROUP ON SOCIAL PREVENTIVE MEDICINE

12 October 1957 ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957

. ... _

COMMENl'S ON PRACTICE FACILITIES AND COMMUNITY RESEARCH OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE

by John B. Grant, M.D.*

~ ~'.;,)

,\:-

* Professor in Public Health and Medical care, School of Medicine, School of Tropical Medicine, University of Puerto Rico.

• WPRO/SOC.. PREV.MED./14

The anomalous situation exists that the only department of a Medical School which does not control its own research and practice facilities is the Department of Social and Preventive Medicine. This should be corrected in every school. Departments of public health should be sufficiently cognizant of the mutual advantages to be derived through delegating to the local Medical School the administration of one of its population units. The contract giving this delegation should also provide the average per capita service costs throughout the nation and preferably an additional differential in acknowledgement of the benefit to the health department of having available a practice field for in-service and refresher training of its own personnel. The contract should include the responsibility of the university for such additional funds as are required to raise the level of practice in the area to one satisfactory for good teaching. Many examples of such contracts are available where university Medical Schools utilize government service hospitals for clinical instruction and for research. The controlled community should be one with sufficient population to demonstrate and undertake research not only in improved technical methods and procedures but also in administration and organization as to the manner such techniques and procedures can most effectively be implemented in a community. Such a population in an urban area should preferably not be less than 250 000. The population in a rural area would differ markedly, depending chiefly upon the size and population of the political units of the country. It cannot be overemphasized that operational research is as important as epidemiological research and research in the pe~sonal health services. The problem of supervisory personnel arises in the case of medical centres not possessed of the various specialized health fields found in schools of public health. This difficulty can be obviated where experts not available in the Medical School could be given concurrent appointments from the health department provided the qualifications, time to be given and the remuneration of the appointees are carefully stipulated in advance of their appointments. This is the procedure followed in the clinical fields of medicine of Medical Schools which do not possess full-time medical specialists on the medical faculty. Similarly, in planning for such controlled community practice and research fields, it should be borne in mind that the service personnel of the transferred community unit should be reviewed in terms of their suitabilit~ to be employed in education services. Another important aspect to be borne in mind in the Medical School undertaking the administration of health care services in a delegated community - is that of standards both for service and for training. Current practice is unsatisfactory where the teaching departments borrow from health departments the utilization of health centres and health units for student training without reference as to whether the services to be observed or participated in meet minimum standards. In the teaching of clinical medicine, it is increasingly the practice for Medical Schools to utilize hospitals which meet minimum service standards, as well as educational standards for the training of interns and residents. Social and preventive medicine should not be satisfied with less in providing itself with teaching and research facilities in the health fields.

WORLD HEAL TH ORGANIZATION STUDY GROUP ON SOCIil.L 1.ND PREVENTIVE MEDICINE

REGIONl.L OFFICE FOR THE 1·m:8TERN Pl,CIFIC 1VPRO/SOC.PREV.MED./15 J4 Octo ber 1957 ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957

DEFINI TIONS

Many of the terms current in discussion of social and preventive medicine and its related topics have acquired a diversity of definitions. 'Ibis diversity hinders the use of terms. In order to forestall possible confusion in the present discussions an attempt has been made to formulate definitions \,hich are submitted to participants herewith. Social medicine has been variously define~At the first World Conference on Medical Education Professor h. stampar gave his definition:"A science dealing on the one hand with mutual relations between social and economic conditions in the health of individuals and groups~ and on the other hand ',lith measures of medical and social care for preventing disease and promoting healthll. Professor T. McKeown,writing in the Journal of hedical the object of teaching in social medicine to be:II

~ducation,

states

To provide an understanding of the problems confron ting us in medicine and of the me3!lS at our disposal for solving them"..

Whereas it would be pointless to provide an encyclopedia of definitions it may l:e useful to attempt a proviSional definition which will embrace the different approaches. The following is accordingly submitted to the conference. "Social medicine is the study of the behaviour of c;lisease in human soc iety. It embraces investiga tion of the role 0 f social organisation in the genesis and course of human diseases and it seeks to determine principles gUiding the deliberate employment of social rrr-ans in the amelioration .of the heCllth of societies. 1I Hygiene is by derivation the stuqy of the nature of health. In many countries it has acquired the specific connotation of that branch of the study of health which is more commonly referred to as environmental sanitation. The term may be defined as the stuqy of the nature of health with a view to its promotion or preservation. nPublic he a1 th

WPRO!SOC!PREV.MED.!15 Page 2 Public health is the practice by social agencies 0 f health preservation. In many countries its scope includes the practice of procedures designed to resto~o health. Its sphere of concern should be considered as imluding all matters related to health and not merely the prevention of corrununicable disease." Preventive medicine is tilat branch of medicine which seeks to matiitain health by preventing diseases. I t may opvrate at either the public or personal levels •. 'Social and preventive medicine is a composite term generally embracing the academic study of social means to preventive ends. It may include the fie lds of social medicine, public health and preventive rredicine. In practice many aspects of medical instruction have been included in syllabuses 0 f Social and Preventive Medicine.· Health care usually connotes the systematic provlslon by public agencies of services for the promotio n of health in individuals." "Co. ehensive health care was defined at the '::olorado Springs Conference on Preventive Medicine in Medical Schools as follows: "Comprehensive hGalth care mew be considered as a concept of coordinated health services directed toward the continuous wellbeing of the individual in an optimal capacity through his own efforts, the guidance of hj.s physician, and th e assistance of various individ uals, groups 0. nl agencies engaged in health activities in the community." Comprehensive roodicine is a term used to denok that its practitioners and advocates do not regard patients as cases of particular diseases but as persons having personal relationships with their families, their society and with their total environment. It recognises that thesG relationship are important in d et"rmining the nature, onset, course and outcoroo of the ]:a tlents' illnessGs.

WORLD HFALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

RIDIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./16

15 October 1957 ORIGINAL: ENGUSH

Manila, Philippines 16-29 October 1957

OBJECTIVES OF THE STUDY GROUP MEE1'ING ON SOCIAL AND PREVENTIVE MEDICINE*

The objectives of the Study Group meeting are:

•

To determine the status of teaching in social and preventive

medicine in the Region with special reference to curricular content and to the avowed or implied aims of instruction in shaping the attitudes of

the next generations of physicians • 2. To determine the nature and extent of the problems involved in

maintenance of existing teaching programmes and where relevant in extending the field of teaching in these subjects; it is recognized that such problems are diverse and relate to adequacy of financial and other support, number and quality of teaChing personnel, formulation of suitable syllabuses and to many other aspects of the need for adequate instruction.

,'"

To suggest where possible lines of approach which may afford a

solution of present problems.

To inaugurate sui table evaluation procedures for the assessment,

of the effect of the present conference on the development of teaching of social and preventive medicine and for compiling information which may be used to gauge the need for further conference.

To attempt to anticipate the needs of the future and the problems

likely to be raised in attempting tD meet these needs, and so far as may be possible to approach a sDlutiDn of such future problems.

*Prepared

by the Secretariat as a basis fDr discussion Df the Study Group.

WORlD HEALTH ORGiJIIZATION STUDY GROUP ON SOCIAL ,'.NIl PREVENTIVE HEDICINE

REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./17 16 October 1957 ORIGINieL: ENGLISH

Manila, Philippines 16-29 October 1957

A SURVEY OF THE TEACHING OF SOCLlL lUID PREVENTIVE NEDICINE IN THE JAPANESE ~iEDICAL SCHOOLS by Professor Yoshio Kusama* Professor Keizo NObec~ Professor Tomio Ogata ,~ Asst. Professor Haruo Katsunuma

A survey was performed throughout Japan in accordance with the questions in Annex II, WPRO/SOC .PREV .MED./IB-l, 16 AUgtlS t 1957, regarding the Study Group on Social and Preventive Medicine. There are 46 university medical schools in Japan at the present time, all answered and below will be found a summary of the findings. 1. Name of College. For~-six

medical schools (21 national, 12 provincial and 13 private).

2. Has the College a specific programme for the training of undergraduate medical students in hygiene/public health/preventive medicine/social medicine? All have specific courses in social and preventive medicine. Credit-hours assigned for the course: Range of the distribution of hours •••••••••• 541-148 hours Mode ••• 0 •••••••••••••• ,. 0 • 0 0 0 0 •• " • • • • • • • • • ••

200.5 hO'U%'s

Ratio of social and preventive medicine to total credit-hours of the medical course (Four Thousand hours are required for undergraduate medical course in Japan).

Range ••••••.••••••••••••• 15.9.% - 3.7% Mode ••••••..•..•.•••••••• 7.%

*Dean, Keio University School of Medicine ,~~Nippon University School of Medicine ,H!*Facul ty of Nedicine , University of Tokyo ~H~~Faculty of Medicine, Universi~ of Tokyo

WPRO/SOC.PREV.HED./17 Page 2

Ratio of lectures to total credit-hours of social and preventive medicine. Range 1100.e .... Range •..• ltlode • 0 0 ••• 0 •••• 0 • 0 " • 0 .... 0 •••••••

•••••••

............... .

47.% - 91.5% 7% 390 - 70 hours 175 hours

......... 0

•

••

•

••••

When olinical year starts. 1 year III semester 1 1/35 2 year I semester 26/35 II semester 5/35 In semester 1/35 I semester 1/35 3 year II selTlester 1/35 (11 schools did not answer clenrly) • 0 ..............

· .............. ·.............. ·............... ·.............. •••• 0 ••••••••••

vJhen social and prevEmtive medicine starts and ends. Start 1 year End 2 year II I semester 12/43 II semester 3 year I 8/43 III semester • • 6/43 II 2 year I semester III 14/43 II semester 4 year I 2/43 III semes ter II 1/43 (3 schools did not answer clearly)

·.

semester • • 1/43 semester 2/43 semester 7/43 semester • • 4/43 semester 7/43 semester 22/43

· . ·. ·.

3. Has the college a special teaching unit (department, division or section) dealing with these subjects? technical staff? Number of departments 1 •••

4#,

If so, what is the total number of professional/

Number of professional staff

...

16/46 27/46 3/46

Range

Hode

... 3 -

16 persons 10 persons

.c,

4. How marw qualified faculty members devote thcir whole time to academic work in these subjects? Range Mode 3 - 16 persons 10 persons

How mnny devote between hc,lf and all their time to these subjects? Part time lecture and post-graduate students Range ••• 0 - 8 persons Mode

•••

3.5 persons

WPRO/SOC.PREV.MED./17 Page 3

5. What field work do the students undertake in the course of training in public health and preventive medicine? a. Visits of observation In all the schools, "field visits" are scheduled in the course on Water-supp~

and sewage disposal plants Food and milk plants Central and local health departments including health centres Research institutions regarding health Industries Welfare clinics for children and the handicapped School health services Rurnl and urbcm communities

etc. b. Taking part in community hee.lth activities Yes ••••

~ 6/46 No ••••••••••• 40/46 0 •• • •

In the majorit,y of the latter, stUdents take part in communit,y health services as extra-curricular activities.

6. Describe the attention paid to industrial hygiene (occupational health) training. fa.

Owing to the great tendency toward urban:j..zation with industrialization, occupational health is tauGht in the social and preventivo medicine course in all medical schools.

7. lure

there any trained medical-social workers on the staff of the hospitals associated with your college? Yes •••••••••• No ••••••••• ••

5/46 41/46

Do they take part in the teaching of undergraduates? A professional medical-social worker takes part in seminar i o~ in one school. 8. Do students carry out any home visits in the course of their clinical training?

Yes

D ••••••••••

1/46

WPRO/SOC.PREV.HED./17 Page 4

9. Describe

co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetricu, paediatricu, etc. a~

As integrated lecture •.•••.•.•..••..•.•.••.•

As joint planning in teaching programme ••••• No •••• "

6/46 38/46

• • • • • • • • • • • • • • • • • • • • • <I • • • • • • • • • • • • • • •

2/M,

10. Do the students get any training in medical statistical methods?

Yes

.......

44/46 2/46

11. Is there a college (or student) health service for the benefit cf under-

graduates? Yes ••••••• 34/46 No •••••••• 9/46 Not answered --- 3/46 12. Comments and plans for the future. a. Do you consider the health services in your connnunity adequate for the field training of undergraduates in public health and preventive medicine? According to the answers obtained from the survey, the following results were reached : Adequate ••••••••••

5/46 Inadequate •••••••• 33/46

Passable ••...•••••

Not answered ••••••

5/46 3/46

OIl,

Schools which answered Iladequate ll have special desirable connections with connnunity health units such that university teaching personnel have additional posts in the connnunity health unit and vice versa. b. Please describe any plans college has for the development of teaching in these subjects. Sufficiency of number of -roaching staff, 2.n:l more budget for research in these subjects ••• ~. 20/46 Co-ordination among clinical medicine, medical social work, community health activities ~ ••• 24/46 Improvement of teaching method and technique, more stress on seminars •.••.•••••••.•••••••••• 12/46

'II,

Exchange professors from outside of country ••.. 8/46 Extablishment of school of public health or faculty of public health •••••••••••••••••• 7/46

•

WPRO/SOC.PREV.MED./17 Page

c. Please describe the problems connected with recruiting sui table personnel who might be entrusted with the development of teaching in these subjects. Better pay for teaching staff ••••••••••••••• 18/46 Exchange of personnel between community health unit and

medical school •••••.••••.•••• te~ching

••••••••••••••

10/46 .

Establishment of special course for training of

personnel •••••••••••.•.•••••••••••• 14/46

,a.

I. W)RL!)

HEl.LTH

ORG[~NIZ:1 TION

REGIONi.L OFFICE FOR THE WESTERN PACIFIC wpRo/soc.PREV~ED./18

STUDY GROUP ON SOCIAL li.ND PREVENI'IVE NEDICINE

21 October 1957 ORIGIlilU,: MEMORllNDUM ENGLISH

Manila, Philippines 16-29 October 1957 from THE llilR VARD SCHOOL OF PUBLIC HEl.LTH

co ncerning a PROGRAMME OF POSTGRADUATE EDUCATION

IN PREVENTIVE MEDICINE liND PUBLIC HEf.LTH CONTENTS

1 2

IN '!RODUCTION WHI~T

IS PREVENTIVE MEDICINE?

1 2 2

PREPAR1l.TION OF TEilCHER$ OF PrtE'JENTIVE MEDICINE

3.4 4

3.1 3.2 3.3

Clinical experience Training in public health Teaching methods Ecology and epidemiology

RECRUI'lMENT AND SEL1!X)TION OF STUDENTS PROPOSED SCHEDULE

5 6

I. r

5.1 5.2

5.3 5.4

First yenr First summer Second year Second summer

6 6

7 7 8

CONCLUSION

*Revised November, 1956 lhis paper was not prepared expressly for the Study Group but is submitted for reference of the participants.

WPRO/SOC.PREV.MED./18 Page 1 1.

INTRODUCTION

•

.J-

Worldwide interest in preventive medicine has resulted in growing demand for qualified personnel. Present leaders have come from a variet,y of disciplines and have had to work out t:1eir own preparation on an individual basis. 'Ibis di varsity of background has provided a natural experiment demnstrating the types of preparation which have proved most useful for teachers of this sp'ocialty. It is clearly desirable to continue to have men of different backgrounds. However, because 0 f the need for teachers to staff the many new departments of preventive medicine in medical schools, it has become necessary to develop a co-ordinated progranme of intensive postgraduate education. 'Ibis memorandum summarizes the thinld.ng leading to the organization of an educational. progranroo for teachers of preventive medicine which is to start at the Harvard School of Public Health in September 19~. 2. WHAT IS PREVENTIVE MEDICINE

The scope of preventive medicine has broadened to include much mrs than the traditional concerns with sani ta tion and epidemic dise'ases. Several substitute terms such as social medicine or environmental medicine have been proposed but have not gained general acceptance. Historically, we find that prescientific medicine was often oriented as much towards the prevention of disease as towards its cure; magic channa am potions were supposed to check the operation of forces responsible for disease. With the growth of knowledge which characterized the development of scientific madicine, there appeared a separation between public health and curative medicine. Each field was so engrossed with its own development that it practically lost touch with the other. In Western countries the decreasing importance of epidemic and contagious . diseases as major health problems .has led to greater concentration of preventive efforts on non-conmunicable diseas3s such as cancer, heart diseases am mental illness which affect large numbers of people. In dealing wL th these conditions preventive measures directed toward individual patients are particularly important rod greater co-ordination of effort between those . practising curative medicine and public health is necessary. Preventive medicine makes use of curative techniques in attempts to control noncommunicable coooitions such as cancer and heart disease, as well as communicable diseases such as syphilis. Conversely in pediatrics, obstetrics and other specialties, there is increasing application of preventive methods as a major part of the responsibilit,y of practising physicians.

In countries of ASia, Africa and other tropical areas where the major health problems continue to be communicable diseases, there is even greater need for integration of preventive and curative medicine. The great shortage of doctors makes it necessary to use the skill and ability of each in ways which will contribute most to the health of the people. These countries can not afford the luxury of providing enough doctors for separate curative and preventive services. Although curative work is needed to meet the most urgent problems, it is

•

TJVPRO/so C. FRE V.MED • /18 Page 2

problems, it is also necess.~ry for all doctors to a ssume responsibility for the application of preventive procedures which will contribute to the health of the general public. There have been several conferencos and meetings in recent years at which attempts have been made to reach agreement on what should be included in preventive medicine. rt.ecent conferences in India ald Latin li.merican have, in general, followed the lead .of the Colorado Springs Conference on "Preventive Medicine in Medical Schools ll and the 1953 j.Jorld Congress on mGdical education. The report of the 1952 Colorado Springs Conference divides C:Jnsideration of the subject into 1. the viewpoint of preventive medicine and 2. knowledge and skills of preventive medicine.

(1) Development of th0 viewpoint of preVGntive medicine in medical students is a general endeavor linked with the teaching programmes in other departments. Students tend to enter medical school with a superficial, but fairly broad understanding of biology and socblogy. .,s they go more deepJ.,Y into the scientific disciplines of medicine, they find it ~ore difficult to rela te what they are learning to an understanding of whole persons living in a complex environment. Later on, as they becolOO mature practitioners of medicine, this ecological understanding develops spontan,Jously. Preventive medicine has a particular responsibility for maintaining in IOOdical students during the formative training period an awareness of ecological relationships of the individual to his environment. The family serves as a natural link between the individual and the community because it is the basic social unit in most cu.ltures. For ter:ching preventive medicine the family is, therefore, a particularly useful focus where comprehensive medical cara can be demonstrated.

(2) That preventive medicine does have special knowledge and skills is increasingly accepted. The fac t th~ t other departmen ts may also use p reventive methods should cause no more surprise than that other departments use the knowledge and skills of physiology or p<:thology. Importnnt contributions to the tee,ching an::! research of amodical fnculty can be made by persons with specialized training and experience in disciplines which have been developed to study 11.00 improve family and community health, such as: epidemiology, biostatistics, co~unicable disease control, specific preventive lOOasures for noncommunicable diseases, sccmtation and environmental hygiene, md ecology especially as it reletee to the study of the social environment.

PREPARATION 05' 5.1

'IE:~CHERS

OF PREJENTI7E l·.EDICINE

CLnica1 experien::"

A @Jod foundation of clinic:-:l training nnd experim ce is important for a teacher of preventive medicine. To speak intelligently about the prevention of a disease, one needs to kn)w the disease. Even more than treatment, preventi)n requires an undorstanding of causes. Sympto~qtic relief or complete cure may be arrived at ompirically. Only r,'trely, however, are good preventive llEasures stumbled upon va thout enough knowledge of causation to identify possi ble points of attack. Many departments of

\VPRO/SOC.PREV.MED./lB Page 3 Many departmentsof preventive medicine are responsible for the supe~ vision of family Care programmes, health centers or outpatient services in which curative and preventive activities are combined. Teachers must be prepared to share in the clinical activities of these programmes in which there are particularly good opportunities for building instruction around patients or families ri th health problems. 1.5 emphasi 5 shifts to health rather than disease, a good understanding of growth and development becomes increasingly important. The years of infancy and childhood are critically important in determining whether the individual will develop into a healthy person.

In addition to fairly wide experience in general medicine, competence in specialties such as internal medicine, pediatrics, obstetrics, oncology or orthopedic surgery may be des ira ble. In some countries a conunand of tropical medicine and infectious disease is particularly useful. With such a foundation, the professor of preventive medicine cm join ward rounds or clinical pathological conferences with assurance, and speak with authority on particular cases. Demonstration of clinical acuzoon will gain for the te~cher of preventive medicine the respect of both medical students and staff memoors and make it possible for him to introduce more effectiveJ.y: the preventive emphasis in clinical situations. Special competence in physiology, microbiology or another pre-clinical science closely allied to clinical medicine is almost as good as qualification in a clinical specialty. With world travel taking so many people to other lands, a department of preventive medicine with proficiency in virology, parasitology or l1\Ycology will gain recognition by aiding clinicians in diagnosing exotic diseases.

3.2 Training in public health

Community efforts to maintain health in mdern society are as important as individual efforts. Preventive medicine by definition deals with both.

•

A school of public health is a logical place to learn the basic disciplines of preventive medicine because subjects such as epidemiology, biostatistics and sanitary engineering are already organized in active departments. In order to enable doctors to take part in community action to control disease, their instruction in preventive medicine must familiarize them with modern techniques of working wLth groups. Without public health training, the teacher tends to present to students only the individual aspects of preventive medicine and is, therefore, unsuccessful in helping them to bridge the gap between curative medicine and public health. Departments of preventive medicine especially in the less developed areas of the world may have opportunities to function as the research and planning arm of official health services. They can contribute to the organization and evaluation of health and medical care progrrunmes. The staff sbould have sufficient standing in public health to merit the respect of their colleagues in this field. 3.3 Teaching methods

, WPRO/SOC .PREV.MED./18 Page

3.3

Teaching methods

Few medical educators have had formal ins truction in hovl b teach. '!he art sud methodology of education are skills they are expected to pick up spontaneously. 1.n ap;Jrentice relationship with a senior professor is traditionally accepted as being particularly valuable ani !llC\Y provide good experience. In a few pL,ces medical school teachers have set out to improve .their teaching methods by organizing their own sGminars and discussi:ln groups. The present course at the H2.rvard School of Public He::lth has an opporto introduce formal instruction in ped~gogical method since it deals with groups of students who are preparing to be teachers. Two types of experience are planned. In special seminars discussion will center on theoretical understandlng of the Irinciples vlhich govern learning processes at the graduate level and specific techniques of teaching. Practical experience will be provided by residency type training in certain medical school departments of preventive medicine vlhere the candidate will learn by teaching under the supervision of experienced teachers • tuni~

. The preceptor programme vlhich is planned will have two important differences from the traditbnal pdtem of one or tvlO junior members of a department working as assistants to a senior professor. First, by training groups of about ten at a time, it will be possible to develop more te2chers. The more leisurely "one man and his disciple" arrangement by itseli cannot meet the present W)rldwide demand. Group preceptorship lOCthods are not new; they have an honorable history reaching back to the i.shrams .of the ancient Hindu Rishis and the Greek philosophers. it. secorti reason for the group preceptorship method is thD.t students are able to learn from each other. Group discussion accelerates the learning process through sharing multiple points of view and ~ diversity of experience. Seminars during the first year should develop e~ch group into a cohesive srroothly functioning educational unit. In the second year When students go to co-operating medical schools, the group educational process .Jill continue. What a traine3 leams in p. particulzr department 1-Jill depend sOlTl6wha t on circumstance and thG strong points of that department. l,{ith students from six or more medic::'.l scho::>ls meeting together in seminar sessions, each hasthe opportunity to learn through his colleagues by selecting from multiple learning situations basic principles applicable under varying coroi tions. Group discussions will promote sharing ()f experience and ensure that the search for understanding gOes deeply into the fundamentals of how to handle problems and develop useful methods. Since all. will have workoo. together during the first yer:..r, 6·:ch sh:lUld be able to 3valuate the reactions of the others to a variety 01 situations and thus v:l.cazoiously to acquire experience more meaningful than that derived from brief personal observation in a number of places, a procedure "hich contributes to a wide view of the problem but not much to depth of understanding.

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5.4 Ec.oloGY apd epidemiology

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WPRO/SOC.PREV~ED./18

Page

3.4

Ecology anct epidemiology

These subjects have such importance in an adequate understanding of preventive medicine that they merit separate consideration. Ecological concepts present a balanced picture of the physical, biological and social forces in the environment as they influence the host and thus the health of individuals and groups. -In "social medicinel! particular emphasis is placed on social environmental factors. This important part of the total ecological picture warrants appropriate attention but not the exclusiye consideration that it has tended to receive in SOIlE Europea'] medical schools. The study of any aberration of health in an individual or population should" in a good doctor" start a reflex tracing of causative factors in an effort to determine the places where preventive measures can be best applied. his thinking should include a projection into future prognosis, with consideration of ways of preventing complicatio rs or spread. This should become so habitual with stu:lents that they will apply it automatically wi th any kind of problem. For students to develop this habit" teachers must consistently practice it. Effective contributions to research are essential if departments of preventive medicine a re to establish themselves firmly in the academic environment of universities. In a questionnaire survey prior to the-Colorado Springs Conference in 1952, it was found that more departments.ofpreventive medicine were concentrating their research activities in epidemiology than in any other field. McKeown in the report of the 1953 Illrld O:>ngress on Medical Education stressed the importance of epidemiology as a major research interest of departments of preventive medicine. Epidemiology is an attractive field of research activi~ because when its skills are combined with those of clinical medicine and laboratory investigation" a balanced team approach to the study of health is possible. Epidemiology as the diagnostic discipline of public health has effectively combined its methods of field experimentation and population ana~sis with clinical and laborator,y techniques in controlling communicable diseases. This asS) ciation of skills promises to be equally valuable in non-comnnmicable conditions.

b. ~-

RECRUI'lMENT AND SELECTION OF STUDEN'IS

Both professional and personal charActeristics enter into the selection of candidates for this programme~ 1. Professional a) b) Good basic medical education Previous postgraduate training or experience in a clinical field or in public health.

Since students are expected to acquire proficiency in both clinical medicine and public health, it is reasonable that candidates enter the field with an adequate foundation in either one or the other. The programme will be suffiCiently flexible and individuali zed to permit each student to take work that will contribute most to his develOPment. c) Teaching experience

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l,lPRO/SOC. PRE V.MED. /JJ3

Page 6

Touching experience

Since the preparation is for positions of responsibility in medical schools, it is desirable that candidates have achieved some statu:ce in medical teaching. TIle work will have more value if they have sufficient experience to select what can 1::.e applied best to t heir own conditions. In this connection it is important that foreign students be assured of an appropriate appointment in institutions from which thay come. 2.

Personal characteristics

The person a1 qua l i ties tha t make n n inspl.rl.ng teacher are difficult to categorize, but they are usually recognizable. The choice of candidates will in large measure determine the success of the programme and the ultimate accomplishments of its graduates.

PROPOSED SCHEDUIE

5.1

First year

Basio courses at the School of Public Health required ol all candidates are Ecology and a special seminar in preventive medicine. In the fourth quarter a weekly s<3minar series is being organized in co-operation with the Harvard Graduate School of Education on educational theory and methodology. Candidates with a clinical background will take additional courses from the master of PUblic Health curriculum, the selection being determined by personal interests and qualifications. J,.n approp riate degree will be awarded depending on previous training and on the work done at the School of Public Health. Those who come from public health work with a degree eqUivalent to a Master of Public Health will probably find M expansion of their clinical experience profitable. Practical eA~erience in mGdical care as part of a family care program of a department of preventive medicine in a medical school, or association with a well organized out-patient service will provide experience in the we of clinical work with which the cmdidate will probably be associated. iLppropriate Hard experience cm be provided through appointments to the house staff of certain hospitals in the Boston area. Concentration in tuberculosis and other specialized clinical fields or research in a laboratory specialty such as microbiology or paraSitology are fUrther possibilities. 5.2 First summer

Students on two year fellowships will usually be in residence during two summers. The first will in general be devoted to research, the nature of the WJrk dependirg on individual interest and competence. Teachers of preventive medicine are expected to do research. Some candidates will be able to undertake a limited research project themselves; more often they will act as assistants in R research team. Epidemiological and laborator,r problems will be directed tow~rd gaining experience in varied skills~ including population surveys and family studies. Methodology .Jill be emphasized more than results.

5.3 Second year

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T~Ro/soc.PREV.MED./18

Page 7

5.3 Second year 5.3.1 Students are to be assigned to departlOOnts of preventive medicine in medicnl schools where vnrious types of preventive mGdicine teaching have been developed. Under supervision students will have opportunity to apply :~hat th6y have learned. The principles which apply to a residency in a good hospital will distinguish this part of the progr:'Jlll1eo Not more than two students will be assigned to and one medical chool. Once a month during the period of residency, the group will be brought together for two days of tlis9ussion in order to point up what they ha;ve been practising and to compare experiences. It is pL~nned that these monthly sessions of the whole group will move as a peripatetic seminar in rotation among the various medical schools participating in the pro gramme. 1. coordinal; ed educatio nal experience sh:lUld result; candidates in each of the departments of preventive medicine will lGarn from the experience of other members of the group and ha-:ve the opportunity to observe the strong points of the teaching programme of each school. Discussion will center first on what is being done in the school and then on what c~ be applied in the various schools represented by the group.

5.3.2 During the final month of the second year all students will be brourht back to Harvard for an intensive period of preparing a concrete programme for their own schools. Detailed curricula for courses will be drawn up and specific points of integration ,-lith other department outlined. Facilities such aa health centers or co-ordinated outpatient departments will be evaluated. Budget and staff will be considered in detail with sources for each. Each candidate will present his program for complete discussion and evaluation by the whole uroup. He will then prepare a detailed written statement which he will have available ~s he goes back to his own school to attempt implementation. [.n alternative arrangement for foreign students unable to stay in the Uni ted States fo r the full two years will be to provide ,Iork in departments in their own countries the second year. The students will not be able to participate in the peripatetic seminar. They will learn hm-llbasic prinCiples have been applied in a local situation similar to the one which they themselves will face. Foreign students vlho take their second year in the United Stutes also should spend two or three months observing the work of selected departments(ofpreventive medicine in their own regions of the world.

5.3.3

5.4

Second summer

Programmes for visits to various centers in the United States will be arranged according to the needs of individual studentso Students from ab~oad returning home could visit institutions in Europe or South'rlmorica to become acquainted with teaching IlBthods and the organization of health services.

CONCLUSION

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WPRO/SOC .PREV.MED./18 Page 8

6. CONCLUSION Indefinable personal characteristics usually distineuish These students are to be given the opportunit,y of associ~ting who inspire their students. ~ observing and emulating them, can acquire the techniques, the information, and the point of help to make them effective teachers. good teachers. wlth teachers candidates view that will

WCRID HEALTH ORGANIZATION

REGICIlAL OFFICE FeR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./l9 Add.l

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

5 November 1957 ORIGINAL : ENGLISH

PROVISIONAL REPORT OF THE WHO S'lUDY. GROUP ON THE TEACHING OF SOCIAL AND PREVENTIVE f'JEDICINE HELD IN MANUAl PHILIPPINES UNDER 'lEE AUSPICES OF THE WESTERN PACIFIC REGION OF WHO FR(J.f 16 - 19 OCTOBER 1957

Addendtun

Add to Annex IV "Completed QUGstionnaires on the Teaching of Preventive and Social Medicine for UndergraJuate Medical Students" Central Medical School l Fiji (WPRO/SOC.PREV.~ED./lO

Add. 5)

RESTRICTED

WORLD HEALTH ORGANlZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./19 29 October 1957 ORIGINAL: ENGLISH

STUDr GROUP ON SOCIAL AND PREVENTIVE MEDICnIE

PROVISIONAL REPORT OF THE WHO STUDY GROUP ON THE TEACHING OF SOCIAL AND PREVENTIVE MEDICnIE, HELD

MANIIA, PHILIPPmES

UNDER THE AUSPICES OF THE WESTERN PACIFE REGION OF WHO lRCM 16 -

OCTOBER 1957

~, -i-I ./ ,)

\ .. ... "

• CONTENTS 1 2 ~OOOCTION

.................................... " .......... " ...................................... " . . .. . ..

OBJECTIVE OF MEDICAL EroCATION - AGENM. ITEM 2 .......................... " .... CURRICULUM CONTENT AND METHODOLOOY OF TEACHING - AGENDA ITEM 3. ORGANISATION OF THE DEPARTMENT - AGENDA ITEM 4 ••••••••••••.••• REIATIONSHIP WITH OTHER DEPARTMENTS - AGENDA. ITEM 5 ••••••••••• COMPREHENSIVE HEALTH CARE - AGENDA. ITEM 6 •••.••.•.••.•••..•••. PRACTICE FACn.ITIES AND COMMUNITY RESEARCH - AGENDA. ITEM 7 •.•. RESEARCH - AGENDA ITEM 8 ................................................. " " " .................. " ANNEXES

3 4 7

3 4 5 6 7

9 12 14

I II

TENTATIVE AGENDA. (WPRO/SOC.PREV.MED./I-Rev.l) PROVISIONAL SCHEDULE (WPRO/SOC.PREV.MED./A-4 Rev.l)

III WORKING PAPERS Relations Between the Department of Social and Preventive Medicine and other Departments of the Medical School (WPRO/SOC.PREV.MED./2) The Teaching of Preventive and Social Medicine. (WPRO/SOC.PREV.MED./3) The Curriculum.

Role of the Department of Social and Preventive Medicine in Community Health Activities (WPRO/SOC.PREV.MED./4) The Scope of Research in Social Medicine (WPRO/SOC.PREV.MED./5) Organization of Department of Preventive and Social Medicine (WPRO/SOC.PREV.MED./6) The Place of Social Medicine in Undergraduate Medical Education (WPRO/SOC.PREV.MED./7) IT COMPLETED QUESTIONNAIRES ON THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE FOR UNDERGRAWATE MEDICAL STUDENTS University of Sydney Medical School, Australia (WPRO/SOC.PREV.MED./IO) College of Medicine, National Taiwan University, China (WPRO/SOC .PREV.!IlIl¥LO) School of Medicine, Keio University, Japan (WPRO/SOC.PREV.MED./IO) Nihon University Medical School, Japan (WPRO/SOC.PREV.MED./lO) School of Medicine, Faculty of Medicine, University of Tokyo, Japan (WPRO/SOC.PREV .MED./lO) College of Medicine, •••

CONTENTS

cOlleie

of Medicine, Seoul National University, Korea (WPRO SOC.PREY .MED./IO)

College of Medicine, University of the Philippines, Philippines (WPRO/SOC.PREY .MED./IO) University of Malaya, Singapore (WPRO/SOC.PREV.MED./IO Annex I) Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines (WPRO/SOC.PREV.MED./IO Annex II) Royal School of Medicine, Phnom-Penh, Cambodia (WPRO/SOC.PREV.MED./IO Add.l) Faculty of Medicine, University of Hong Kong (WPRO/SOC.PREV.MED./IO Add.2) University of otago Medical School, Dunedin, New Zealand (WPRO/SOC.PREV.MED.jlO Add.3) Faculty~ Medicine and Pharmacy, University of Saigon, Saigon, Vietnam (WPRO/SOC.PREV.MED./IO Add.4)

TEXTS OF ADDRESSES Speech of Welcome by Dr. E. Virata, Acting President of the University of the Philippines Message from Dr. M. G. Candau, Director-General, World Health Organization, Geneva Opening of Meeting of the Study Group by Dr. I. C. Fang, Director, WHO Regional Office, Manila

VI VII

LIST OF PARTICIPANTS, OBSERVERS AND STAFF (WPRO/SOC.PREV.MED./A-2 Rev.l) OBJECTIVES OF THE STUDY GROUP MEETING ON SOCIAL AND PREVENTIVE MEDICINE (WPRO/SOC.PREV .MED.j16) ,

VIII PRINCIPLES FOR PARTICIPATION BY THE SECRETARIAT IN THE STUDY GROUP MEETING ON SOCIAL AND PREVENTIVE MEDICINE IX DEFINITIONS (WPRO/SOC.PREY.MED.j15)

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. WPRO/SOC.P.REV.MED./l9 Page 1 1

INTRODUCTION

The decision to hold a study group meeting on teaching of preventive and social medicine 'WaS determined by many considerations. Although similar conferences have been held elseWhere in the world during the past few years these have mainly been local in scope in the sense that participation has been confined to a particular region and discussion has been limited to consideration of aims and problems specific to that region. In many countries of the Western Pacific Region of WHO creation of departments responsible for the teaching of social and preventive medicine is currently proceeding and there is often little experience locally available of a kind directly related to the problems being met. Useful though reports of conferences in many parts of the world may be in a general sense, they do not usually provide answers to questions posed specifically by characteristics of countries in this region. Accordingly it 'Was decided that in view of the relatively similar problems and situations met with in the various parts of the Region together with the different stages of developnent of teaching in social and preventive mediCine, it might be profitable to facilitate the interchange of experiences wi thin the area fer the benefit of all. Considerable thought 'Was given to the question of representation at the meeting. Evidently it 'Was necessary to invite holders of chairs in social and preventive medicine in universities in the Region. However it 'Was felt that since many of the problems facing these departments stem fram difficulties in gaining acc~ptance for programmes in their subject wi thin the total medical curriculum, it 'Was necessary to secure representation of other departments of the medical schools. The most efficient method of dealing with this necessity was thought to be achieved by inviting, as well as heads of departments of social and preventive medicine, the deans of medical faculties. In addition many other interested bOdies were invited to be represented by observers. A list of participants is to be found in Annex VI. In order to have a central body attached to the meeting which might offer expert advice both on content of agenda and on technical problems related to the functioning of the meeting it 'Was decided to invite two consultants. Accordingly Dr. Ed'Ward Grzegorzewski and DiI. Chia-chi Ma. were invi ted to serve as consultants. Dr. Grzegorzewski is Director of the Division of Education and Training Services of WHO, and Dr. Ma is Dean of the National Defense Medical Centre, Taipei, Taiwan. Since the meeting 'Was to be held under the auspices of the.WHO Western Pacific Regional Office it 'Was natural that the meeting place should be in Manila where the Regional Office is located. However the office buildings themselves offer no facilities for the accommodation of a meeting of the proposed size. We were fortunate to be offered the use of the building of the Institute of Hygiene, University of the Philippines, and we are grateful to the acting President of that University, Dr. E. Virata, and to the Dean of the Institute, Dr. Hilario Lara Who extended us every conceivable assistance and courtesy. The meeting was •••

WPRO/SOC.PREV.MED./19 Page 2 The meeting 'WaS held from 16-29 October 1957. Long before this date preliminary work 'WaS embarked upon by a planning committee Which began work in November 1956 and 'WaS composed of the Regional Public Health Administrators, the Regional Adviser on Education and Training, the Regional Adviser on Health Education and the Chief, Administration and Finance for the Region. Preliminary work included preparation of questionnaires to be circulated to all intending participants, and aimed at presenting to the planning committee information on content and arrangellE:nt of existing teaching in social and preventive medicine in universities of tte Region. These were completed and returned before the meeting convened. In addition, working papers on varipus suitable topics were requested from some of the intending participants. These papers appear as Annex III to the report. The planning committee also made itself responsible for a provisional detailed agenda for submission to the participants for their approval and for modification if desired. This agenda is included in the report. About two weeks before the conference met Dr. Ma arrived in Manila to join the planning committee in arranging the ilIlll1ediate details of the meeting. A week later Dr. Smith, WHO visiting lecturer in the Department of Social Medicine and Public Health, University of Malaya, also arrived to join the secretariat of the meeting which was to be composed of Drs. Shiga, Ma, Grzegorzewski and Smith. Their functions were to attend to details concerned with the smooth running of the meeting. Matter relating to these functions is included in Annex VIII to the report. In addition to the agenda for discussion of teaching of social and preventive medicine, a number of visits to places of interest and importance in related fields was arranged. These places included the College of Medicine, University of the Philippines and the Philippine General Hospital and we are grateful to the acting President of the University, Dr. E. Virata for his kindness in arranging this visit. The group also visited the University of Santo Tomas and we are grateful to Dr. Virgilio Ramos for this facility. Visi ts to the Manila City Health Department were arranged through the kindness and courtesy of Dr. Mariano C. Icasiano, and to the Rural Health Demonstration and Training Centre by the Department of Health. The visits included opportunity for discussions and were accorded keen interest by members of the meeting. The meeting participants were were accommodated or French and the began on 16 October and for several days before this date arriving in Mania by air from all parts of the Region. They in the Luneta Hotel. All participants spoke either English meeting was conducted in these two languages.

•

At the opening session Dr. E. Virata, acting President of the University of the Philippines began by welcoming the participants to the Philippines. He declared that their presence was "a tribute to the humanitarian spirit Which motivates" their work as scientists. He went on to say that his own Government was greatly concerned with the health of its people. This he felt 'WaS partly due to increasing recognition of the responsibility of the state for health and partly due to recognition that health is a prerequisite for advancement in an industrial society. Dr. Virata's speech is reproduced in Annex V to the report. Dr. I. C. Fang •••

• WPBO/SOC.P.REV.MED./19 Page 3 Dr. I. C. Fang, Regional Director, opened the meeting. His address is ::-eproduced in Annex V to "the report. At the opening session, Dr. Lara, Dean of the Institute of Hygiene, performed the duties of master of ceremonies with a thoroughness matched only by its vivacity.

Dr. Grzegorzewski read a message from the Director-General which appears in Annex V to the report. Before proceeding to the detailed business of the meeting the participants were addressed by the Regional Adviser on Health Education on the principles of the group dynamics as applied to groiql discussion.

The second item on the agenda after the opening session was the discussion of objectives in medical education. For this and for subsequent sessions the procedure for discussion was as follows. The whole st~ group was divided into smaller sub-groups which met separately to deal with each item of the agenda. After completion of their discussions each group reported to a plenary session held for each item. For the second item there were three subgroups but this number was reduced to two for later items. In the main all groups agreed to follow the provisional annotated agenda. Before discussion began it was thought desirable to discuss the definitions of varioUl terms submitted by the secretariat with a view to reaching a measure of agreement and avoiding unproductive discussion of the meaning of terms. It was felt generally that these definitions were useful except that the group felt unwilling to accord any special definition to the term "health care" and suggested this term could be understood only in the particular contexts in which it might be employed. 2 OBJECTIVES OF MEDICAL EDUCATION - AGENDA IT:EM 2

Discussion of objectives centred around the objectives of medical education as presented by the American Association of Medical Colleges and quoted in full in the working paper by Dr. lara. One group felt that ~se were statements of detail and that a more general summary of the objectives of medical educa~n was desirabl;. The main objective they felt should be stated as the provision of enough practitioners of comprehensive medicine to meet the needs of society. A participant raised the question as to how far the needs of society for specialists (including research workers) should be met by considering the selection of suitable candidl;t.tes at undergraduate levels. It was pointed out that some medical schools make provision for research training of undergraduates wo on completion of their research rejoin the medical course. Future academic staff are frequently recruited from among students who have been selected for this special training. It was felt that if recruitment of specialists is entirely delayed tmtil after graduation, graduates may be lost sight of when they work in areas outside the sphere of influence of the medical school and they may be lest to the specialist branches of the profession. Not all participants were able to agree with this viewpoint and many felt that prior needs were met bytbe production of basic medical practit1oners. Discussion of the •••

WPRO/SOC.PREV.MED./19 Page 4 Discussion of the objectives of teaching in social and preventive medicine followed. To a great extent this revollled around the question of "Whether complete integration of preventive and curative medicine should be aimed at or "Whether at the other extreme it might be desirable to establish two kinds of undergraduate training for doctors specialising respectively in the preventive and curative fields. O:cJ. the whole this latter view was rejected. One group felt that the aim in preventive and social medicine teaching was to make the student actively interested in social needs with respect to the medical services he could offer and to acquaint him with the role of social organisation in the aetiology distribution, course, prevention and treatment of disease. In addition the stage of development of many ,countries in the area made it necessary for any physician to have acquired 'some of the basic skills of public-health practice. It was also important to present the field of social and preventive medicine in an attractive light so as to counteract the inherent glamour of the curative field and enCoura@e a fair proportion of the more able students to make fUture careers in health practice. All discussion emphasized the need to imbue the medical student with a philosophy orientated towards recognition of the preventive function of medicine "Whether his subsequent career was to be primarily in preventive or in curative medicine. It was recognized that no sharp line can be drawn between preventive and curative aspects of many medical procedures. Discussion then turned to considering the role of the physiCian in the community. After some confusion occasioned by the different connotations of the word "physician" in English ani American usage it was agreed to adopt the American usage and define a physician as any medical graduate enga@ed in some branch of the practice of his profession. His role was generally defined as that of responsibility for the maintenance of optimal health in his society. To such an end it was necessary that the physician should adopt a positive role primarily concerned with promotion, preservation and restoration of health. It should never be forgotten that a physician is a citizen with civic duties which are greater rather than less in consideration of his specialized knowledge. 3 CURRICULUM CONTENT AND MEl'HOOOWGY OF TEACHING - AGENDA ITEM 3

...

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Discussion in the two groups differed in form and in emphasis but no serious disagreement occurred between the fundamental attitudes represented in the two groups. Both groups were sure that content bore a direct relationship to local needs and therefore there would be differences as to "Whether individual subjects should be included and also differences in the degree and kind of emphasis required by individual aspects of the curriculum. These differences would be determined by the different situations confronting medical practice in different countries. Both groups stressed the need for a practical approach in the clinical years. There was felt a great need for inclusion of "traditional" public-health teaching since its problems were not 001,. among those met daily by the medical worker in many countries in the Region but were also valuable in imparting a sense of history of the achievements of preventive medicine. Content of the curriculum is most easily discussed in relation to the distinct phases of medical education Which are almost universally found. These may be termed the pre-medical, the preclinical and the clinical. The pre-medical course ••

WPRO/SOC.PREV.MED./l9 Page 5 The pre-medical course may be taken to represent the teaching before the student embarks on the more specifically medical basic sciences. The traditional requirements in this part of the course have usually been confined to Physics, chemistry and biology. It ¥laS felt that to these should be added elementary psychology, elementary social science and mathematics at least up to a level which would facilitate later comprehension of the quantitative aspects of disease. It ¥laS felt that some of these requirements might be met, at least in part, if biology could be re-orientated to¥lards human biology, especially social biology in its more quantitative aspects. It was felt that some acquaintance with the liberal arts was generally desirable in entrants to medical schools. In the pre-clinical years, traditionally occupied by instruction in anatomy, physiology, biochemistry and to some extent microbiology and pathology, the interests of social and preventive medicine would be fostered by considering the nature of normality with respect to health, growth, social fUnction and psychological develo~nt. To this end biometry or biostatistics should be taught in these years. Other related fields of instruction would include nutrition (probably best covered by departments of biOChemistry), history of health, mental health, and human genetics. At this time some instruction should be offered in environmental hygiene to provide continuity. In the clinical years some of the more pressing problems in social and preventive medicine should be incl~Q. The n~ture of health resources together with a discussion of their provision in both economic and practical terms should form a basic introduction to the consideration of the various special agencies, medical and social which are part' of the community's total health resources and which should be freely employed in the promotion and maintenance of community health. At this stage also the epidemiology of disease should be considered. Attention is drawn to the desirability of teaching epidemiology in its modern sense of the study of the behaviour of diseases in human populations. It should no longer be restricted to consideration of the spread and control of communicable disease. It ¥laS emphasized that discussion of curriculum content did not necessarily involve the direct responsibility of the department of social and preventive medicine for actual tuition in all these fields. It was the responsibility of this department to urge the inclusion of these subjects and approaches and to make itself responsible for general supervision of aspects of the programme for which it did not assume direct tuitional responsibility. From the above discussion it is clear that participants feel that social and preventive medicine has a place in all tuition extending throughout undergraduate training. The apportionment of time between the various aspects of this study would be a function of the individual situation and needs of individual medical schools. Emphasis on the importance of teaching through clinical media was apparent in all discussions. Methods of incorporating a clinical approach were discussed and generally discussion revolved around the idea of the clinico-social medical conference conducted by representatives of both

•

clinical and preventive

WPRO/SOC. PREV .MEn. /19 Page 6 clinical and preventive and social departments. In addition, we should like to stress that while we have little influence in the matter of selection of deans of medical schools, it would generally be in the interests of integrated teaching if choice of deans were made from men with the widest possible approach and background. This would gradually ensure tre acceptance of the social approach to medicine within t~ clinical courses. The ~uestion of how much participation in local health and medical care programmes should be encouraged as a part of undergraduate teaching, was then raised and whereas there was considerable difference between the amounts of such training considered necessary there was general agreement that some such participation might be valuable. I t was felt that 'where health centres provided by agencies other than the university were used for teaching purposes the university should be at least be represented in policy-making bodies related to the centres. To some extent this objective was met by the practice of making joint appointments to teaching and health staff. Participation in teaching on the part of local health officers was usual to some extent and was to be encouraged. Additional methods of teaching received some discussions and particular reference was made to the field survey as an educational technique. A curriculum in social and preventive medicine. Pre-medical course. Elementary pscychology Elementary social science Mathematics Pre-clinical course. The nature of normality _ social, psychological, developmental Biostatistics Nutrition Mental health H = genetics History of health Elementary environmental hygiene Clinical course. Health resources - needs, administration of services, etc. Work of· health agencies - including practical instruction Epidemiology and control of diseases Medical ethics and law Preventive techniques At the plenary session on this item of the agenda the point was raised that much of the curriculum content that had been discussed was only partly relevant to the diSCiplines of social and preventive medicine and that we must beware of making social medicine responsible mainly for filling the gaps left by courses in the other parts of the curriculum. It was necessary to develop a •..

WPRO/SOC.PREV.MED./19 Page 7 to develop a clear and coherent syllabus wich "Was unequivocably and indisputably the proper domain of this specialty and that teaching should be concentrated upon a presentation of this syllabus. Despite tm fact that as in other branches of medicine tle re is overlap into related fields, we should also note that as in other branches of medicine there is a defined, subject matter Wich it is the responsibility of departments of social and preventive medicine to develop and teach. "" ORGANISATION OF THE DEPARTMENT - AGENDA ITEM 4

Both groups agreed as a preliminary basis for discussion that there were three phases of tm functiom of any university departmmt. These were teaching, research and connnunity service. The depo.rtment of social and preventive medicine differed in no "Way from other departments in this respect. Most of the participants agreed that of these functions teaching WBS the most important although one view "Was expressed that the first duty of an academic department "Was research. Lively discussion centred on the means of achieving a proper balance between the three functions and it "Was finally agreed that as in so many aspects of the problems being discussed by the study group the final decision on details must be determined largely by the situation prevailing in each area. In considering teaching functions the part to be played by the department of social and preventive medicine in co-ordinating teaching of these subjects "WaS dscussed briefly. A question Wich provoked some discussions "Was raised by one participant wo considered that the department of social and preventive medicine should be responsible either in wole or in part for some of the training of para-medical workers. The contrary view "Was put that this would involve loss of prestige within the medical school and would increase the problems of gaining acceptance for the department. The more general view "Was that some responsibility might well be undertaken for part of the para-medical training needed by the connnuni ty and that ac ceptance of such responsibility would improve tbe contact of tbe department with the community in Wich i t "Was situailed. The varying degrees of community service Wich should be provided were discussed at length. On the one hand i t "Was urged that the major service offered "Was the training of medical students and the prosecution of research, wereas at the other extreme it "Was suggested that the department of social and preventive medicine should provide actual community health care. In support of this view it "WaS stated that in many countries, knowledge of preventive and social medicine had outstripped implementation of its implications and that departments should give a lead"by providing an example of the kind of health care wich can be provided. Most participants felt that wile actual provision of health care services was usually outside tbe scope of university departments these departments should usually playa role in the community's development of services either by acting in an advisory capacity or by actually being represented on administrative and policy making bodies. Continuous service might be provided by part-time appointments between the university and the ccmnunity health services. Consultative service on behalf of the rest of the university or on behalf of the wole community should be one of the functions of the department of social and preventive medicine.

All participants agreed ••

WPRO/SOC.PREV.MED./19 Page 8 All participants agreed that a separate and independent department 'Was necessary wi thin the medical school for carrying out all these functions. In general two basic reasons were given. First, however tIE integration of preventive and social teachiIl!: with the clinical aspects of medicine might be developed, it 'Was essential that there should be some department accepting full responsibility for such teaching and for co-ordinating efforts throughout the medical school. Second, it 'Was necessary to develop research in the field of social and preventive medicine and for this purpose a specially trained staff was needed. On the question of Whether teaching in social and preventive medicine should be continuous or integrated with other teaching in the medical school most participants felt that both approaches were desirable. So far as the subject 'Was a separate discipline with separate subject matter it was important to develop a coherent and continuous course. However some aspects of teaching might be better conducted by integration with other teaching. The value of team work in the clinical social ward round justified some importance being attached to this method of teaching. The question of staffing was next discussed. The total personnel strength of several of the departments represented by participants was outlined and certain principles were defined. The number of personnel should depend on the size of the school and the number of students, Whether or not postgraduate teaching was also carried out, the scope of the curriculum, and the extent to Which community services formed a part of the department's normal work. 'In addition, availability of suitably qualified persons must be a limiting factor. The main requirement was quality and this was particularly important in the case of the l:J.ead of the department. He should cOllJllland the respect both of his colleagues and of the students and should be able to accept responsibility for the development of the course. It was particularly important that the first occupant of a chair in preventive and social medicine in any school should be of high calibre since respect for the department depended so much on first impressions formed by related organisations both within and without the school. It was felt that a full-time professor was required and that indeed in the absence of a full-time professor the department could not be said to exist as an independent departJrent. Ideally there should be at least one other medically qualified member of the staff both to assist the professor and to provide for replacement of the head of the department in the event of temporary absence of the professor. In addition part-time lecturers were usually required to cover the various specialized instruction necessary. Participants from Japan were able to contribute to this discussion an account of the situation in their country. No school of medicine in Japan has less than two professors in trefield of social and preventive medicine and one school has three full-time professors. In one of the countries represented at the meeting there is no full-time professor or other staff. Discussion next centred around the question of What training was necessary for members of the academic staff of the department of social and preventive medicine. Differences of opinion were evident on this question. Some felt that for heads of departments, experience in clinical medicine up to consultant level was required While others felt that a more general clinical experience was necessary. Others felt that some experience in public-health prl)ctic& might be valuable. All were agreed that teaching ability was indispensable and it ••

•

WPRO/SOC.PREV.MED./19 Page 9 indispensable and it was suggested that teachers in medicine as in other fields should have a genuine liking for students and for teaching. One group formulated its views as follows: 1.

5. 8. 6. 7.

Training was best accomplished by actual work wi thin a department. Some of the specialised skills of social and preventive medicine should be acquired. Some post-graduate training in public health was desirable. Teaching training of the kind offered currently in the Harvard Post-graduate School was valuable. Experience in teaching in social and preventive medicine or in allied fields was useful. Experience in research in an established field was desirable. Some academic distinction was necessary. Personal qualities likely to command respect both of colleagues and of students was indispensable.

The important question of recruitment and the difficultie s commonly experienced next received attention. Disparities between the financial rewards of teaching and the practice of clinical medicine were a great barrier to the recruitment of high-class personnel. This question was a vexed one and applied outside the field with which we are directly concerned. It was agreed that the labourer should be worthy of his hire and that salaries should be on a par with those available to colleagues in tile clinical fields. In brief, it was generally agreed that a separate independent department of social and preventive medicine was necessary to assume responsibility for teaching and research. Staffing require~ents might vary with different circumstances but a minimum requirement was the appointment of a full-time head of the department and it was general~y desirable that there should be at least one other full-time associate. Recruitment would be difficult unless financial rewards comparable with those in other branches of medical teaching were available. A coherent course in the subject of social and preventive medicine should be the primary teaching requirement of the department but in addition the department should assume some responsibility for tuition in related fields and should make arrangements with other departments Df the school for joint instruction. As in other academic departments, active research within the field was a fundamental necessity and the department should also be able and willing to provide consultative and other services to the local commun1ty.

REITATIONSHIP WITH OTHER DEPARTMENTS - AGENDA ITEM 5

Both groups began discussion of this item of the agenda"" by gJ.v~ng an account of the relationships prevailing in their own schools. These varied from cordial co-operation on the one hand to the extremes of autonomy and isolationism on the other. Much of the variety is attributable to differences in the historical evolution of the systems of medical education. 1n general clinical teachers displayed an awareness cf the need for co-operation particularly in their teaching at the patient I s bedside • All schools employed to some extent the technique of clinical conference at which all aspects of a case were discussed. In didactic and formal lecture instruction co-operation is less apparent. Co-operation depends to some extent on the leadership of the dean, and of the senior 5embers of the faculty. This is particularly

true with reference ••

WPRO/SOC.PREV.MED./19 Page 10 true 'With reference to administrative matters relating to the curriculum. One group made a point of the observation that most medical schools had examples Dfautbnomic departments or of departments where incumbents of senior offices were ill disposed to friendly cO-Dperation 'With other departments. Despite the presence of such departments the medical student probably attains a reasonable comprehension Df the inter dependance of the various disciplines. This is prDbably due tD the acceptance on his part of all disciplines as a traditional part of the total teaching of medicine and we should guard against assuming th&t he will as easily integrate the newer subjects. It was felt that the student shDuld gain more experience of the practical applications of integrated approach. The grDup sought a positive rather than a haphazard approach to this problem. In considering the typesaf co-ordination required between departments Df social andpreveutive medicine and Dther departments one group 'Wished tD develop some general principles. In every case consideration should be given tD the personality factors extant in a faculty. A major cause of non-coDperatiDn was felt to be a psychological personal element. Ideally a common spiri t of approach to all prDblems in "the medical school is desirabl.e. It was felt that this might be more readily attainable if there was a common training experience frDm the ~ast. In addition, the role of the dean was considered to be impDrtant in securing co-ordination. It would be desirable tD have active leadership frDm the dean ani the grDUp expressed the DpiniDn that all deans dD not have adequate authority either by virtue of personal characteristics Dr by virtue of administrative structure. Such an active leadership might initiate CDmmon study groups whDse functions would be tD include the kind Df cO-Dperative approach to te~ching that was mentioned in the agenda items 5.2 a, b, and c. This grDUp adopted the recommen~~tions Df variDus members that the following items were often valuabale in securing a CDmmDn approach: 1. faculty promDtion boards, 2. lectures by basic scientists during clinical years, 3. extensive use of specialists in lectt~es by other clinicians, 4. more social activity among the faculty. The question was constantly stressed throUghDUt the discussion. Opportunities for informal friendly cDntact were often inadequate and members Df the group felt that mDre might ~e achieved by such contact than by more formal devices for liaisDn. The other group approached the problems by a more specifically detailed consideration of items cDntained in the agenda. As a . first consideration they agreed to add a fourth item (d) to the others in agenda item 5.2. This was "informal sDcial cDntact". The questiDn cf integratiDn of medical teaching was first dealt 'With. After hearing an accDunt of the difficulties experienced by one university represented at the study group in adopting a fDrmal integration plan on the lines Df that employed in the Western Reserve Medical SchDDl they agreed that formal integration did not provide a whole answer to the need .for cO-Drdination. Integration where practised shDuld have regard fDr the needs of some subjects to be develcped along different directions from others. It was rarely satisfactory to adDpt formal integr~tion programmes without much carefUl discussion wi th all departments. At certain points of the curriculum integration m,ght be advantageous •••

WPRO/SOC.PREV.MED./19 Page 11 be advantageous but many subjects (e .g. b.iostatistics and public-health administra.tion) would never fit easily into integral teaching programmes. Three disadvantages were stated Wich it was agreed were inevitable concomitants of' integrated courses. First, the value of carefully spaced repetition was often lost when all repetition was closely related in time. Second, integration of the curriculum discouraged the student from making his personal integration of the different aspects of medicine; we must always beware of underestimating the student's ability to think for himself and fit together his own concept of medicine. Third, integration of the various courses in the curriculum often involves the disintegration of the individual course and prevents a coherent development of the ma.n:y subjects which require continuous presentation in any orderly form.

•

Rejection of formal integrstion schemes does not however involve rejection of the need for co-operation in some aspects of teaching. For example, joint seminars are considered valuable in that they present at one time several distinct approaches to a similar problem. Such seminars were held to include "grand rounds", and clinico-socio-pathological conferences. Combined appointments wi thin the medical school were not generally felt to have much to offer except in so far as we cannot always appoint full-time personnel. Stress evaluade the in the total of community was placed on the need for social medicine to discuss and role of therapeutic as well as other procedures as instruments community services directed to~ds promotion and maintenance health.

In discussing tm role of exchange of services in the co-ordination of various medical school departments, the point was raised that this had different aspects in newly established departments from those in more firmly accepted departments. Whereas no one was in much doubt as to the kind of services available from old established departments such as th:Jse of surgery or medicine, it was not always clear to other departments that the department of social and preventive medicine had any specific services to offer, nor was it clear what kind of services might be expected. This makes it necessary for the department to develop a service which it can offer. Such services have often been in statistical or epidemiological fields. Some stress was placed on the need for facilities for social intercourse between members of various departments. Many problems stemmed from lack of sufficient opportunity for friendly personal relations to be developed both between members of different departments and between persons occupying positions of varying seniority even within departments. In discussing item 5.4 of the agenda the group wished to amend it so that the word "integrated" should have the senae usual in non-specialized diSCUSSion, and should not connote any specific type of formal integration as the word'is used in much current discussion of medical education. The group felt that the teaching resFonsibility of the department of social and preventive medicine was to present to students the social implications of the practice of medicine and the occurrence of disease. To some extent this should be

WPRO/SOC.PREV.MED./19

Page 12 this should be achieved by formal development of a separate course, but it may also involve some participation in clinical teaching. In general the total responsibility of the department could be summarised as teaChing, research, advisory, co-ord1na.tive and catalytic services directed as appropria 12 towards the school, the students and the community. In the plenary session on this item of the agenda there was a discussion of the nature of formal integration progranmes. Whereas there was considerable agreement that there was need for more co-operation between different departments of the medical school it was felt that no simple formal integration programme was likely to achieve this in the absence of detailed consideration of the needs of individual courses. Such detailed consideration was best achieved by tree discussion of common problems, preferably at joint faculty meetings.

COMPREHENSIVE HEALTH CARE- AGENDA ITEM 6

Since there was'widespread feeling that there was much lack of personal acquaintance with the subject of comprehensive heal~n c~re, it was decided not to discuss this item in groups but to convene a plenary session so that those who have had experience of the development of this type of project might present their views to the whole study group.

Dr. Grzegorzewski opened the discussion on this item. He first dealt with sub-item 6.1 "What is the concept of comprehensive health care." He urged a dynamic approach and felt that due to the processes of evolution to which comprehensive health care was subject, no formal definition should be attempted. The matter might be approached from two angles. First 1 organisation of comprehensive health care might be widespread or local and might take in a variety of different health and social care services. For example we might contrast the clearly defined but relatively limited types of comprehensive care services provided by such social organisations as the armed forces with the widespread and more diffuse services organised on a country-wide basis as for examp~e in Great Britain or the U.S.S.R. Second, there was need to consider the needs for health care of different social groups whether these be thought of in terms of family units or wider groups. '!he next point of the agenda wh.ich considered the responsibility of the medical school for teaching comprehensive medicine raised a number of important points. Medical schools had generally been in the vanguard of advances in the concept of medicine. This was natural. But medicine had advanced from the point where the general practitioners could meet all the recognised needs for health care, to the point where the allied and specialist services had grown into a large and complex system. The patient could not be expected to be aware of all these services which medicine had to offer him and it became the duty of the general practitioner to marshall all the resources available for the service of his patients. Investigators in Harvard had been depressed by the ignorance existing as to the extent of available health care. Medical schools had a responsibility to ensure that the physician was informed as to the existence of all health care services and as to the methods of invoking their aid in the total treatment of his patient. The next •••

WPRO/SOC.PREV.MED./19 Page 13 The next sub-item on the agenda was the question of methods to be used in teaching. Dr. Grzegorzewski recaJ.led that it had for I18ny years been traditional to rely in medical education on what was essentially an apprentice system whereby the student learned from following the daily work of his clinical teachers. Was this still an adequate system? In some universities, specialized educational methods were in use for securing a comprehension of the scope of total health care. In Puerto Rico senior students were assigned to a comprehensive clinic and had actually to meet patients and marshall the necessary resources of the clinic on behalf of the patient. This was only one of several possible ways of achieving the desired end and in some places it might be felt that no departure from the traditional methods was needed. It was probably necessary to acquaint the student with the scope of existing health services before he entered his clinical years so that he would begin clinical stud~es with a grasp of the total services available. It should be remembered that we are not always in advance of social conditions in our medical thinking and frequently we are adapting our own ideas to fit existing conditions. But we might consider sOIOOtimes whether we should not exert some influence on administrative evolution so as to secure social conditions propitious to health. Dr. Katsunuma then described a practical experiment in comprehensive health care with which he had been associated. In the medical school of the University of Tokyo an experiment in comprehensive health care had been based on a small 2OO-bed hospital serving a population of about 150,000. There had been attached to this hospital several special guidance units. These came under a central ,administration. The department controlling all the guidance functions had under it a geriatric unit, a well-baby clinic, a mental health cliniC, a social service unit, a eugenic counselling unit and an industrial health unit. Personnel held joint appointments in SOCial, medical and clinical units. One function of the unit had been to conduct multi-phasiC screening. Case work, group work and mass screening and survey methods were all used in the work of the health guidance unit.

Dr. Nobechi contributed of health services in Japan. surveyed and the incidence of social and economic data were

to the discussion an account of the administration Stratified samples of the population had been various diseases had been estimated. In addition, collected fol'" use in assessing needs.

Dr. Kusama described the industrial health services of Japan. He showed how these functioned and gave anaccount of their effect in reducing the incidence of some diseases notably tuberculosis.

Professor Lloyd Davies discussed the contribution to the discussion by Grzegorzewski. He sounded a note of caution in accepting comprehensive health services as a means to reducing demandS on medical services and pointed out that an increase in the amount of declared sickness was to be expected as a result of the introduction of a national health service.

Dr.

Dr. Icasiano then described the health services of the city of Manila. Use was made of the necessity to secure a medical certificate before obtaining a marriage license, to direct people to the health services. This was pa.r1i.cularly useful in achieving better utilization of the pre-natal and mater-nity

services.

...

WPRO/Sr C.PREV.MED./19 Page 14 services. Professor Lloyd Davies wondered what safeguards were used to protect individual liberty in such a system.

Dr. Lichtenwalner felt that the discussion was departing from the specific subject of the function of the department of social and preventive medicine in teaching comprehensive health care. Dr. Smith agreed and proposed that primarily the function of such departments in this respect was to teach the importance of maintaining the total health of whole communities. He felt that students should be presented with principles to guide them in their thinking about the role of medicine as a community service. Nationally-sponsored comprehensive schemes were not the only way to achieve comprehensive health care. Developments would be best achieved if the medical profession was properly oriented in its thinking. On the ~uestion of the responsibility of departments of social and preventive medicine for creating comprehensive health clinics, he felt that there was much to be said for this but a disadvantage might be that where universities provided such clinics other agencies might feel themselves absolved from the need to make any provision and the whole community might be the loser as a result. Dr. Grzegorzewski felt that the discussion had been profitable and hoped that some continuation of discussion might be undertaken by the separate groups.

PRACTICE FACILITIFS AND COMMUNITY RESEARCH - AGENDA. ITEM

Discussion began with the ~uestion of whether community facilities should be used in medical education and there was complete agreement that all facilities related to health should be used. These might be held to include rural and urban health centres, student health centres, chronic disease treatment centres, mental health clinics and hospitals. Use should be made of the statistical, evaluative and planning services of governments. One group felt that discussion of the next items might be held over until special interest groups had met and discussed them. This group felt that facilities such as those they had visited in and around Manila were fine examples of the kind of community health resource which should be widely available for teaching purposes. Rural centres often provide a more valuable teaching subject since they often cover a wider spectrum of comprehensive service than do their urban counterparts. Although governmental and other agencies usually set a high standal!d in service prOvision, contact with a university provides a healthy' source of constructive criticism which can often elevate standards. Joint faculty appointments may serve a similar function. The group noted with regret that current relationships between ministries of health and of education in some countries often impede use by medical schools of community health resources as teaching material. The group was emphatically of the view that universities must be functionally autonomous and that political impediments to collaboration with the community should be minimized. Where schools experience difficulty in securing use of health facilities consideration might be given to the development by universities of their own health clinics. These might be developed from a student health service. It was felt that such projects would do much to demonstrate the university's possible contribution to maintenance of high health standards. The other •••

WERO/SOC.PREV.MED./19 Page 15 The other group also was entirely convinced that community resources should be employed in teaching and no discussion was felt necessary. There are many different ways in which the resources of the health services of a conmunity can be utilized as a teaching laboratory. The use of health centres for this purpose was universally agreed upon. However it was urged that at such centres there must be a proper balance between teaching and service and that one must not be sacrificed for the other. Experience at such centres can involve both observation fIld partiCipation on the part of the student. M:>st speakers felt that of the two, particpation was the better learning exercise. The group felt that "public-health sightseeing" was desirable for medical students when properly and carefully organised • Visits should be made to water and sewage undertakings, even 'though detailed knowledge of" the working of such plants was not required of the undergraduate. wcal circumstances must" always determine the amoun't'" and tYJ?e of such demonstrations. It was pointed out that the teaching hospital itself was a valuable community service usually freely available for teaching. ?>V.ny teaching hospitals are assuming new functions in social and preventive medicine, particularly in developing health centres. Clerkships in the various fields of he~lth work were valuable methods of securing a. l:.'?r~"ledge of their functions. The group d1sOUMed experiments proceeding in some countries in affording students the opportunity to work with general practitioners. The best method was considered to be that of attaching students to existing practices but the L~ternative method of creating general practice units within the teaching hospital was a useful method where general practice facilities were for one reason or another unavailable. One of the groups decided that topic 1.5 which dealt with research was of sufficient importance to justify its separate discussion as a new agenda item which -uol\J.d be numbered item 8. Accordingly it would be considered later. There were two reasons for this decision.

1. The research functions of departments of social and preventive medicine tend to be neglected and therefore deserve special emphasis in this study group. 2.

Earlier divisions of the function of departments into teaching, research and service would seem to justify a separate agenda item for each of these three roles and teaching and community service had already had special items devoted to them.

It was felt that the expression ''colllIllUnity research" as published in the agenda was too limiting since cOlllIllUnity research was only one aspect of the legitimate research interests of departments of social and preventive medicine.

RESEARCH - AGENDA ITEM 8

The views of both groups are included under this heading although one group preferred to discuss the subject under the agenda item originally allocated to it. It was agreed •••

WPRO/SOC.PREV.MED./19 Page 16 It was agreed that the working paper onthis subject gave a fair outline of the scope of research and the categories proposed in the paper were acceptable. Discussion then turned to a more general consideration of research function and methods. Many participants admitted the claims of research but felt that was more important and should not be sacrificed to research. Much of had been and would continue to be in applied fields especially needed departments, but the legitimate interest of departments of social and medicine in more fundamental research must be recognised. teaching research by outside preventive

Much of the research would be epidemiological in character and would be concerned with iBolating aetiological factors likely to be amenable to control. Examples were discussed of the multiple causation of disease and the choice of control measures which such a concept introduced. It was agreed that a fundamental difficulty not always successfully avoided by investigators was that of identifying appropriate questions to which answers were required in order to advance knowledge. The choice between large-scale surveys and "case-work approach" was not always easy to make. Many problems required the large sample methods whereas others might be dealt with by a case" work approach. Most research projects today involve biometric methods, Social and preventive medical research still relies on descriptive methodology and works by Fisher, MorriS, Simmons and Wolffe were commended to the group for study. There was a difference of opinion between the two groups on the role of the medical student in research. One group was polled to discover the extent to which research methods were introduced to students and it was found that nearly all schools represented were active in teaching research methods. The other group felt that research only involved the student in that it was the main source of teaching subject matter, and that engagement in it imparted vitality to a teacher's presentation of his courses. Some knowledge of epidemiological methods was advocated however and the works of Pickles were commended as suitable reading material for students. In research as well as in teaching, social and preventive medicine departments had much to offer the community. Their contribution might be summarised as: 1. the personnel, facilities, time and enthusiasm of a co-ordinated team seldom available elsewhere for the study of clinical or operational problems; the integrated and comprehensive approach to research which discards traditional restrictions and which employs the tested methods of all sciences.

-i

'" PROVISIONAL SCHEDULE

< WPRO/SOC.PREV.MED./A-4 Rev.l

•

STUDY GROUP ON SOCIAL AND PBEVENTIVE MEDICINE Manila, Philippines 16 to 29 October 1957

'ctober

0730

0830 - 1000

1000-1015

1015--=-lT30 Continuation Agenda 3 (group) Agenda 2 (plenary) Agenda 4 (group)

1330

1400 - 1530 Agenda 2 (group) Continuation

1530-1545 Tea break If

1545--:-T7JO Continuation Continuation

6, Wed. 7; '!'hu. 8, Fri. -9, Sat. '1, Mon. '2, Tue.

Tea break Agenda 1 (opening session) Agenda 3 (group) Agenda 3 (group) Agenda 4 (group)

" "

U.P. College of Medicine, Philippine General Hospital, Institute of Hygiene Agenda 3 (plenary) Agenda 5 (group) Agenda 6 (panel) Man i 10. City Tea break If

U.P., Diliman, Rural Health Demonstration and Training Centre Agenda 5 (group) Agenda 5 (plenary) 4geuda 7 (group) Tea break If If

Continuation Continuation

Agenda 4 (plenary) Agenda 7 (group) Continuation Teachi~

'3, Wed. '4, '!'hu.

Health

De partm en t Continuation Tomas

Continuation Field visit to

Tea break

i H H

'5, Fri.

Organization of If " Rural Health Centres and Units (plenary session room)

-? tr ~

~ c

in Rurnl Health tRoom No. 101)

University of Santo

Teaching in Urban Health (Room No. 102) Cultural Studies (Room No. 105)

., · ~ · ~

--..

.!t 26, Sat.

tober , Sat.

0730

0830 - 1000 Agenda 7 (plenary)

1000-1015 Tea break

1015 - llJO Teaching in Urban Health (Room No. 102)

1330

-~J:IIOO---;;:-J.530 ·-J.5?jJ~5

. J.)45- J.730

(JQ

Clinical Teaching (Philippine General Hospital) Cultural Studies (Room No. 105) Field Visit (Quezon Institute of Tuberculosis)

~· ro I\l

g ~ CD e >: ....

:x>

He He

•

,• ~

8, Mon.

Clinical Teachingg>oup (Visit to Philippine General Hospital) Cultural Studies (Room No. 105) Tea break

Field visit

Community Development

projects

Field Visit to the Tala Leprosarium

9, Tue.

Tea break Suonary of discussions 1'uture plllnning General evaluation (plenary)

Closing session (plenary)

(

;a,

... ,

<p(

.. WORKING PAPERSf The Teaching of Preventive and Social Medicine. (WPRO/SOC.PREV.MED./3)

~T.PRO/SOC.PREV.MED./19

ANNEX III

Relations Between the Department of Social and Preventive Medicine and Other Departments of the Medical School (WPRO/SOC.PREV.MED./2) The Curriculum.

Place of Social Medicine in Undergraduate Medical Education (WPRO/SOC.PREV.MED./7)

These have already been distributed to the participants.

WPRO/SOC.PREV.MED./19 ANNEX

COMPIEI'ED QUESTIONNAmES ON THE TEACHING OF PREVENTIVE AND SOC IAL MEDICINE FOR UNIlERGRADUATE MEDICAL STUDENTS* University of Sydney Medical School, Australia (WPRO/SOC.PREV.MED./10) College of Medicine, National Taiwan University, China (WPRO/SOC.PREV.MED.!lO) SdQool of Medicine, Keio University, Japan (WPRO/SOC.PREV.MED./10) v

Nihon University Medical School, Japan (WPRO/SOC.PREV.MED./10) School of Medicine, Faculty of Medicine, University of Tokyo, 'Japan (WPRO/SOC.PREV.MED./10) College of Medicine, Seoul National University, Korea (WPRO/SOC.PREV.MED.!lO) College of Medicine, University of the Philippines, Philippines (WPRO/SOC.PREV MED./10 University of Malaya, Singapore (WPRO/SOC.PREV.MED./10 Annex I) Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines (WPRO/SOC.PREV.MED./10 Annex II) Royal School of Medicine, Phnom-Penh, Cambodia (WPRO/SOC.PREV.MED./10 Add.l) Faculty of Medicine, University of Hong Kong (WPRO/SOC.PREV.MED.!lO Add.2)·

University of Otago Medical School, Dunedin,New Zealand (WPRO/SOC.PREV.MED./10 Add.3) Faculty of Medicine and Pharmacy, University of Saigon, Vietnam (WPRO/SOC.PREV.MED./10 Add.4)

These have already been distributed to the participants.

• WPRO/SOC.PREV.MED./19 ANNEX V

TEXTS OF ADDRESSES 1 Speech of Welcome by Dr. E. Virata, Acting President of the University of the Philippines Message from Dr. M. G. Candau, Director-General, World Health Organization, Geneva Opening of Meeting of the Study Group by Dr. I. C. Fang, Director, WHO Regional Office, Manila

tIt-

WFRO/SOC.PREV.MED./19 Annex V Piige 1 1 ADDRESS IILIVERED BY m. EHRIQUE T. VIBIi.TA, ACTIN} P~1DENT, UNIVERSID OF THE PHIDPPINES, WELCQ'llNG ~UMBERS OF 'lliE STUDY GBJUP ON SOaJ:AL AND PREVENTIVE l'lEDICDlE, INSTI'lUTE OF 'HYGIENE, OCTOBER 16, 1957

Ladies and Gentlemen, ,ilY Friends ~ It is a distinct pleasure to w91come you this morning on behalf of the University of the Philippines. The commonness of interest that binds us on this occasion strikes me as one of the most significant endeavours of our time. In this collective effort

we take strength from the fact that neither race nor creed nor politioal ideology divides us. We know that there is much WJrk to be done. There is a great deal there is widespread

of public apathy, ignorance, and superstition to overcome; poverty to combat in our desire to rid mankind of diseases.

Indeed there seems to be no better proof at the moment, than a regional conference of this kind, tr~t

we all recognize the urgency of our mission - above

and beyond, mind you, the rivalries and suspicions that plague our world today. I regard your pr~sence

in this conference then as a tribute to that humani-

tarian spirit which motivates' your work as scientists. I hope that you will have a truly fruitful session. Our awn gover.nment, if you must know, is of its people. gr~atly

'concerned with the health

That is as it should be.

In terms of figures, the Philippine

government has appropriated for the current fiscal year more than t'47-million out of its total budget for the care ani treatment of the sick and for tho prevention of diseases. This amount easily represents tho third largest single :t.tem in the It is

budget, exceeded only by education and national defense, in that order. encouraging that our departm~nt

of hoalth, which

is directly charged with the

duty of lweping tHs nation healthy, appears to bu gaining more and more importance in the eyes of our budget officials and those who formulatd policies. is, of course, a good sign. /1 personally •••• All of this

WPRO/SOC.PREV.MED./19

Annex V page 2 I personally interpret this growing concern as the product of two main factors. The first is that the government is properly conscious of its While') privata institutior.a

.., •

obligation to take care of thu health of the nation.

and practitioners contribute generously to this upkeep of national health, it cannot be gainsaid that the basic responsibility rests wi th tho State. 'ilie second

factor, to my mind, is tho direct boaring of national health on the success of our industrialization program. Thu immediate goal of such a program being the creation

of employment opportunities, it could nourished and sickly.

not make any headway if people were ill-

It is the experience of the highly d0voloped countries that economic prosperity is directly related to the health of the people. cious circle in a way. The situation is a vi-

Unless a country bocane sufficiently well developed

economically - and this usually means industrially - its population is likely to have a poor state of public health. On the other

hand, unless - as I have

pointed out - its people are healthy, there is no manpower to develop a country's economy. In my way of thinking, t he critical role of public hygiene - and specifically I have in mind social and preventive medicine - is to pierce this circle at one point and introduce the necessary reforms. of courso. But it can bo done. It will not ba an easy task,

And if al'\Ybody has to do it, it must be the work. I hasten to add that I

scientist engaged in this particular line of speak'purely as a than certainty. l~n

and I offer these views more in a ,spirit of speculation I am

Like you, I have a great faith in scientific knowledge; ~,ait

confident that men of science will not try to solve mankind I s problems.

idly while statesmen BI:Id diplomats

I feel I must add, before leaving the subject, tha't industrialization is only one of the many reasons why a program of

II II

public health must succeed.

There arE' other cqlally important fi0lds of human endeavour which directly depend on public hoalth for their success and I hav~

no intention of minimizing them here.

II t

appears •••

Annex V Page 3 It appears to me cogent" nevertheless, that in an ago such as ours when the national populations are increasing at tremendous rates that the attention of this distinguished assembly might be also turned to th e social implication of social and

WPRO/SOC.PREV.MED./19

proventive medicine.

The

rapid incrG3se of populations

due

to the

su:::cess of thG public hoal th workurs will generate long range problems which should be taken into consideration in any public health conference for the sake of maintenance of a stable social ord",r. I do not intend to elaborate in this

8ubiect any further except to mention that this increase in population is disturbing to many students of demography. At this point, I am tempted to mention another compelling aspect of social and preventive medicine. If I sound somewhat reluctant to do so, it is because

I know that you are extensively engaged in such an activity, and that whatever I may

say is superfluous.

I rQi'or to the decisive role of research.

You will

agreo with mo that without wise and sustainod resoarch, scientific knowledge would be at a standstill. In our own comtry such an imperative activity must, unforBecause of the

tunatcly; be borne largely by gov0rnmont-supported institutions.

tremendeus expenditures involved and very little corr0sponding immediate profit, many of our private educational institutions have shied away from research. simp4r cannot afford it. How about priva'to industry? Somo of thorn do carry on research, but most4r But Many

of tro applied kind, when th0y soek new products, nG1, drugs, new brands. .~

again, generally speaking, the state of our economy is suCh that private enterprise is either limited or still undeveloped. blem of finance, in othor words. I imagine that In a large measure this situation holds true in many of our neighbouring countries in Asia. Whoro such conditions obtain, tho logical cenWe are up against tho same pro-

ters of resoarch, as in the Philippines, arc the statu-supported institutions of higher loarning and sci;,;ntific laboratorios. The UnivtJrsi ty of the Philippines is Vll

proud to be ca rrying on a s ignifi cant portion of this res oarch

rk lUldaJ:! it s

If" '1 ••• "' J.nancJ..a

WPRO/SOC.PREV.MED./19 Annex V page 4 financial limitations. But principally, it seems to me, its duty is to educate and train too persons who will eventually carry on research and expand the horizons of knowl~dge.

I see in such cor£erences as this an incalculable contribu-

tion to the stimulation of indGpendent scientific investigations arld in the dissemination of nawly discov0red knowledge. Tho benefit /"accruing from our contact is, in this sense, mutual. On

our We

own part, we welcome, the invaluable help and the advice of our colliagues.

are given a chance to know what they are doing along the same line of endeavour. Evvn such routinary matters as curriculum content and methodology of teaching begin to assume a new and interesting colour in thi s conference. In tm inter-

change of ideas, we £rCl.nkly hope to adopt those which in our honest opinion would improve our own stock of knowledge. As a parting thought I wish to thank, on behalf of the University of th e Philippines, the World Health Organizotion and all the government as well as private entities which havu made this cmference possible. I am offering the modest and

limited facilities of tho University to all the delegates, if nCGdcd, and I personally wish them a truly fruitful and pleasant stay.

** *

WPRO/SOC.PREV.MED./19 Annex V Page 5 2 MESSAGE OF DR. M. G. CANDAU, DIRECTOR-GENERAL, WORLD 1ffiALTH ORGANIZATION, GENEVA, TO THE STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Mr. Chairman, Ladies and Gentlemen:

Please accept my apologies and regrets for not having been able to be present at the opening meeting on Wednesday.

In fact my travel plan provided

for my arrival in Manila on Tuesday afternoon, but unfortunately, the weather conditions stopped the flights and we had to wait until the next day. These

adverse circumstances prevented me from delivering at the opening meeting the message in beha1f of the Director-General of the Wor1d Health Organization. _A

May I then be permitted to do it now.

Dr. Candau wanted me to express to

~ou

his most sincere greetings and best He particularly appreciates the

wishes for successful and fruitful discussions.

contacts being established between the Organization and the medical teaching and research institutions. Indeed it is in the medical schools and their The students

various departments that the future of medicine is determined.

educated by you will advance medicine and health of the people entrusted to their care. Their broadening outlook on the role of the doctor in the community and the

role of medicine in modern society in genera1 is the basis of our expectations of still better, hea1thier and happier future of the peop1e. Right in the beginning of its work, WHO has realized that any long-term , t

hea1th progress in any country can only be achieved if there were avai1ab1e sufficient number of proper1y trained medica1 and re1ated personnel. At the

same time, it was felt that advances in medica1 sciences and in socia1 and community developments require certain adjustments in the preparation and orientation of the doctor. And indeed, a very strong trend in medical and Many national,

also non-medical opinion can be observed in this direction.

/international and • .••

WPRO/SOC.PREV.MED·/~9

Annex V Page 6 internationa~

and world-wide ccnferencesstudy the problem and search for the ways

cou~d

be solved.

It is significant that practically

all these discussions considerable In WHO's own

emphasis was put on social and prcver.tive aspects of medicine. programmes this matter also received due consideration.

The Expert Committee

on Education and Training analyzed the problem in a broad perspective and rJade some general widely-applicable recoomendations. detai~ed

This was followed by more

regional studies and conferences, e.g. in Europe, Latin America and

in a number of countries in Eastern Mediterranean and south-East Asia Rugions. We feel that gradually the impact of al~

these studies and conferences, and parwi~

ticularly of the efforts of the medical schools and their professors

bring

about the desirable results, i.e. to obtain a well-balanced medical education programme where curative, preventive, social and psycho~ogical

aspects will

receive their proper share in harmony with each other. Group wi~l

We hope that this Study

bring us closer to this goal in the Western Pacific Region through the Your experience and

exchange of ideas and experiences among the participants. views are however also very wil~ valuab~e

to our

col~eagues

in other regions who The WHO is very We know

receive with appreciation the results of your discussion$.

gratefu~

to you for your acceptance of the invitation to this meeting.

how busy you are in your own responsible positions, and we decided to encroach on your valuable time only because we were convinced that it cause of our common interest. I have also a pleasant duty tv express Dr. Candau's and the WHO appreciation for the hospitality of the Government of the a noble tradition of this country to extend Phi~ppine a~l

wi~l

serve a

usefu~

Republic.

It has become

facilities for

internationa~

meetings and international co-operation altogether.

also ••••

... WPRO/SOC.PRHV.MED./19 Annex V Page 7 I also wish to thank our immediate hosts, the Institute of Hygiene, ~nd

its inspiring Head, Dr. Lara, under whose leadership the Institute has acquired an international reputation •

. .i

..... 3

page ADlRESS OF Dr. I. C. FANG, WHO REGIONlIL DIRECTOR FeR 'lliE WESTERN PACIFIC, AT THE OPENING SESSIOl~ OF T& STUDY GROUP ON SOCIAL Al'l'D PFWl.c:NTIVE liEDICINE, 16 OCTOBElt 1957, Ii~S 'YLTUTI: 01" HYGIl'NE, l'IaNIL.A, PHll.IPPINES.

WPRO/SOC.PREV.MED./19 Annex V

I bring you my cordial groetings and those of Western Pacific. I ~xtend

Regional Office of the

to you my bust wishes for a satisfactory, stimulating

and productive meeting. TIle World Health Organizotion is one of the specialized ag.;;ncies of tre United Nations UhoS6 purpose is to assist governments in improving their health sorvices, so that each individual may attain the highest possiblo level of health, which is his inalienable right. In our affortsto assist Member Govornment<j in the improvument of health, one of our major interests is to encourage tho co-operation of private and government hoalth 8.ctivitiLs within c01.U1tries, as well as to integrate health into any nctional too d~velopment

plans.

Such co-operation anti integration are based on

belief that social and aconomic development in any c01.U1try must go hand in

hand, and that there is an inescapable interdependence of problems in such fields as education, haalth, agriculture and welfare. I am most happy iudeed that it is possiblo for so many specialists in medical education and Bocial and prevanti VG medicine to be gathered in Nanila to

discuss ways and m6aI1 5 of improving or making further improvements in th6 teachi!l8 of social and preventivo modicine. We are all aware of the fundanental importance of cultivatinG the social

and preventive concept in tho minds of the medical student since medicine is rapi becoming morc and more comprehensive. For this reqson the promotion and main-

tenance of conununity ond individual h-JDlth have become not only tho concern of hoolth aga:.ncies but also of tho practitionors of ITEdicine. 1,10r0 and moru the teaching of mudicinu has expanded beyond thl3 confines of the medical school and hospital, anJ is beginning to transeemd the conventional !barriers that •••

WPRO/SOC.PREV.MED.j19 Annex V page

..... for us all to take stock of the situa-

barriers that have existed between academic departments and between institutions and communities. It is time, therefore,

tion we are in, in relation to the needs of the people for better heal th care. This meuting of the. prasent stuqy- group would not have been possible but for tm courtesy extended by th.. Philippino Government, arrl particularly by the Institute of Hygiene of the University of the Philippines. thank the Acting President and Duan La~a

I want, th",refore, to they have shown to I am sure

for the

hospitali~

the; World Health OrGanization and the lVIcmber Countries of this Region. that the discussions which will take place will be most helpful

in formulating

your own plans for the future improvGl'llent and strengthening of the teaching of social and preventiv8 medicine. I now have the pleasuro of declaring this Study Group meeting officially opened, and following a short recess, the group will mUut again for tm necessary pruliminaries boforo work be;;ins at 2 0' clock

••

in the afternoon.

shall be. looking with I3r"at interest to your de1iborations and wish you every success in your endeavours.

......

WPRO/SOC.PREV.MEp./19 ANNEX VI LIST OF PARTICIPANTS I OBSERVERS I STAFF AND OTHERS

I. AUSTRALIA

PARTICIPANTS

Dr. Ronald Elliott MURRAY Senior Lecturer in Preventive Medicine and Sub-Dean, Faculty of Medicine University of Sydney Sydney Dr. Max MEYNARD

CAMBODIA

Director, Royal School of Medicine Phnom-PEmh r J,

Dr. Pruoch VANN Deputy Director of Health Services Direction of Health Services Phnom-Penh

CHINA

Dr. Huo-Yao WEI Professor of Paediatrics and Dean, College of Medicine National Taiwan University Taipei, Taiwan Dr. Kung Pei CHEN

Professor, Director of Institute of Public Health and Head, Department of Preventive Medicine National Taiwan University Taipei, Taiwan FIJI Dr. A. R. EDMONDS

Principal Central Medical School Suva HONGKONG Dr. Leslie G. KILBORN Professor of Physiology and Dean, Faculty of Medicine University of Hong Kong Hongkong

JAPAN •••

iTPRO/SOC .Pf'.EV .MED. /19 iIJl$).I;t WI. "'r-r . r r, I Page 2 JAPAN Dr. Yoshio ICUSA.WI. Professor of Preventive Medicine and Dean, Medical School Keio University Shinjuku-ku Tokyo Dr. Keizo NODECHI Professor of Public Health Nihon University Medical School Oyaguchi-machi, Itabashi-ku Tokyo

Dr. Tomio CGATA

Professor of Serology and Chairman of Curriculum Committee Faculty of Medicine University of Tokyo Tokyo Dr. Haruo KATSUNUMA Assistant Professor of Public Health Faculty of Medicine University of Tokyo Tokyo

KOREA

Dr. MYUNG Choo-Wan Professor of Psychiatries and Dean, College of Medicine Seoul National University Seoul Dr. SHIM Sang Whang

Professor of Preventive Medicine College of Medicine Seoul National University Seoul NEW ZEAIAND

Sir Charles HERCUS Professor of Social and Preventive Medicine Dean, Medical School University of otago Dunedin Dr. Gordon O. L. lEMPSTER Director, Division of Tuberculosis Department of Health, and Externa~ Examiner in Preventive Medicine for Otago University Medical School, Wellington

PHILIPPlNES •••

'tlPRO/SOC . PREY .l'1ED./l9 .\C"'l~);

R""" .': ) PHILIPPDlES

Dt'. Agerh.0 B.M. SISON Professor of Medicine and Dean, College of Medicine University of the Philippines Manila Dr. Hilario IARA Dean, Institute of Hygiene and Professor and Head of the Department of Hygiene and Preventive Medicine, Colleges of Medicine, Dentistry and Pharmacy, University of the Philippines Manila Dr. Virgilio RAMOS Dean, Faculty of Medicine University of Sto. Tomas Manila Dr. Manuel Ma. AYCAROO ProfesSor in charge of Preventive Medicine Faculty of Medicine University of Sto. Tomas Manila

SINGAPORE

Professor Ernest S. MONTEIRO Professor of Clinical Medicine and Dean, Faculty of Medicine University of Malaya Singapore Professor T. A. LLOYD MVIES Professor of Social Medicine and Public Health Faculty of Medicine University of Malaya Singapore

VIETNAM

Professor Trinh Van T~T Arting Dean, Medical Faculty Univer,ity of Saigon Saigon. Dr. Nghiem Lenh THIEU Member, Medical F&culty University of Saigon Saigon II.

OBSERVERS

WERO/SOC.PREV.MED./19 Annex VI Page 4 II. OBSERVERS

Dr. Romeo Y. ATIENZA Assistant Professor of Preventive Medicine and Public Health Institute of Medicine Far Eastern University Manila, Philippines Dr. Jose CUYEGKENG Acting Dean, College of Medicine University of the East Manila, Philippines Dr. Trinidad GOMEZ Acting Chief Health Education and Training Division Department of Health Manila, Philippines Dr. Mariano C. ICASIANO

City Health Officer Manila Health Department City Hall Manila, Philippines Dr. R2,IDon MACASAET Dean, College of Medicine Manila Central University Balintawak, Caloocan Rizal, Philippines Dr. James H. MATTHEWS Adviser in Medicine College of Medicine Seoul National University Seoul, Korea Dr. Regino G. PADUA Professorial Lecturer in Hygiene and Preventive Medicine College of Medicine Manila Central University Balintawak, Caloocan Rizal, Philippines Dr. Lauro H. PANGANIBAN •••

lit

-.-~

WERO/S0C.PREV.MED./19 Annex VI Page 5

Dr. Lauro H. PANGANIBAN Dean, Institute of Medicine Far Eastern University Manila, Philippines Dr. Arsenio C. REGAIA Special Assistant Department of Health Manila, Philippines

III.

STAFF

Dr. Edward GRZEGORZEWSKI

Director, Division of Education and Training Services World Health Organization Geneva, Switzerland Dr. Chia-chi 14\ Academic Dean National Defense Medical Centre Taipei, Tai-wan Republic of China Dr. Hidetoshi SHIGA Regional Education and Training Adviser Western Pacific Regional Office World Health Organization 29th Street, Port Area Manila, Philippines Dr. Alwyn SMITH WHO Lecture"" in Public Health Faculty of Medicine University of Malaya Singapore

IV.

OTHERS

Dr. Craig S. LICHTENWALNER

c/o American Embassy Saigon Vietnam

WERO/SOC.PREV.MED./19 ANNEX VII

OBJECTIVES OF THE STUDY GROUP MEETING ON SOCIAL AND PREVENTIVE MEDICINE*

(WERO/SOC.PREV.MED./i6)

This has already been distributed to the participants.

, "

WPRO/SOC.PREV.MED./19 ANNEX VIII

PRINCIPLES FOR PARTICIPATION BY THE SECRETARIAT IN THE STUDY GROUP MEETING ON SOCIAL AND PREVENTIVE MEDICINE 1. It should be a principle that members of the secretariat are to function as ordinary participants of the seminar except that:(a) (b) members of the secretariat should not accept nomination as leaders, recorders or reporters of their groups, members should bear in mind that they should not unofficially adopt roles more appropriate to such official positions.

2. By virtue of their special positions as experts in their fields or of their acquaintance with the objectives of the meeting or by virtue of both these considerations, members of the secretariat can contribute usefully to discussion. They should bear in mind however the objectives of the meeting and realise that primary among these is the determination of the status of teaching and the problems confronting it in the institutions from which participants have come. Accordingly participants should fe'el encouraged to present these questions to the meeting without feeling that they are present to listen to the general views of experts. To this end members of the secretariat should:(a) (b) (c) (d) (e) (f) observe the extent to which various pBrticipants feel able to contribute to discussion, refrain from expressing general views which might discourage the more retiring participants from speaking, stress in their contributions to the discussion the importance of hearing all problems, refrain from dismissing particular problems as easily to solve, epeak more from local experience than from general theory thus encouraging other participants to do like'vise, at all times give way when it is felt that other members would like to raise pertinent points.

3., Members of the secretariat have detailed functions which relate to the comfort and convenience of participants. Maximal value in these functions can only be achieved if participants are able to feel that members are easily approachable. Much can be done during discussion to inculcate such a feeling in participants. Since members of the secretariat are or have been employed within WHO they may be apt to assume greater acquaintance with WHO affairs among participants than is justified. They should endeavour to anticipate difficulties aiming from participants' scant acquaintance with WHO, the Philippines and the WPRO generally.

4. Since some of the participants will be hearing discussion and talking part in a language other than their mother tongue, members should attempt to set a standard of plain speaking and refrain so far as is possible from employing specialised jargon.

WPRO/SOC.PREV.MED./19 ANNEX IX

(wPRO/SOC.PREV.MED./15)

DEFINITIONS *

This has already been distributed to the participants.

·'

..1uJ WPRO/SOC.PREV.MED./A-l STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE ManilA, Philippines 16 to 29 October 1957 SCBEIXJU: OF A,RRIVAIB' Name From ETA and Fliet No. DeSi~tion Consutant Chia-chi Ma Taiwan 1 October CT 153 1120 hours Staff Singapore 9 October PA 834Alwyn Smith 2105 hours Participant Singapore 13 October PA 834E. S. Monteiro 2105 hours Singapore 13 October PA 834T. A. Lloyd Davies Participant 2105 hours Participant Cambodia l4 October A:F l84 M. Meynard 1320 hours Participant cambodia P. Vann l4 October A:F l84 1320 hours Participant Vietnam 14 October A:F 184 T. V. Tuat 1320 hours Participant Vietnam 14 October A:F 184 N. L. Thieu l320 hours Vietnam 14 October A:F 184 C. S. Lichtenwalner Observer 1320 hours Fiji A. R. Edmonds Participant 15 October EM 240 0655 hours Participant R. E. Murray Australia 15 October EM 240 0655 hours Charles Hercus Participant N. ZealAnd 15 October EM 240 0655 hours G.O.L. Dempster Participant N. ZeaJAnd 15 October 11M 240 0655 hours H.Y. Wei Participant Taiwan l5 October CT 153 1120 hours Participant K. P. Chen Taiwan 15 October CT 153 1120 hours Y. Kusama Participant Japan 15 October A:F 185 1645 hours Participant K. Nobech1 Japan 1.5 October AF 1.85 1645 hours Participant T. Ogata Japan 15 October A:F 185 1645 hours Participant H. Ka.tsUUl.lI!8 Japan 15 October AF 185 1645 hours C. W. Myung Participant Korea 15 October AF 185 1645 hours S. W. Shim Participant Korea 15 October A:F 185 1645 hours James Matthews Observer Korea 15 October A:F 185 1645 hours L. G. Kilborn Participant Hongkong 15 October PR 301 1815 hours E. Grzegorzewski Consultant Geneva 16 October AF 192 1330 Hours

Dr. Dr. Dr. .v

Hotel AccollllllOdation ArtIry atid Navy Club Luneta Hotel Luneta Hotel w.neta Hotel w.neta Hotel w.neta Hotel w.neta Hotel Luneta Hotel Luneta Hotel Luneta Hotel Luneta Hotel Lurlta Hotel w.neta Hotel w.neta Hotel Luneta Hotel w.neta Hotel Luneta Hotel Luneta Hotel Luneta Hotel LuDeta Hotel Luneta Hotel w.neta Hotel w.neta Hotel Luneta Hotel

Dr. Dr. Dr. Dr.

.. ,

Dr • *Dr. Dr. Dr.

Sir Dr. Dr. y

Dr. Dr. Dr.

Dr. Dr.

Dr. Dr. *Dr. Dr. *Dr.

~ .. '

ibM MnrlA to be confirmed; hotel. bookings tentative.

...

WPRO/SOC.PREV.MED./A-2 Corr.l

• STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16 to 29 October 1957 LIST OF PARTICIPANTS, OBSERVERS AND STAFF Corrigendum

Page 4 "Dr. Craig S. LICHTENWALNER

United States Operations Mission to Vietnam c/o American Embassy Saigon, Vietnam" Dr. Lichtenwalner is not attending the Study Group meeting in the capacity of an official observer of ICA.

• \.

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

Mmila, Philippines

16 to 29 October 1957 LIST OF PARTICIPANTS! OBSERVERS AND STAFF I. AUSTRALIA PARTICIPANTS

Dr. Ronald Elliott MURRAY Senior Lecturer in Preventive Medicine and Sub-Dean, Faculty of Medicine University of Sydney Sydney Dr. Ruo - Yao WEI

CHINA

Professor of Paediatrics and Dean, College of Medicine National Taiwan UniverSity Taipei, Taiwan Dr. KUng Pei CHEN Professor, Director of Institute of Public Health and Head, Department of Preventive Medicine National Taiwan UniverSity Taipei, Taiwan CAMOODIA Dr. M:l.x MEYNARD

Professor of Pathology and Director, Royal School of Medicine Phnom-Penh Dr. Pruoch VANN

Deputy Director of Health Services Direction of H~lth Services Phnom-Penh "

FIJI

Dr. A. R. EDKlNIl3

Principal Central Medical School Suva HONG KONG Dr. LesJ.ie G. KILDORN Professor of Physiology Acting Professor of Social Medicine and Dean, Faculty of Medicine University of Hong Kong Hongkoug JAPAN •••

•

-".

WPRO/SOC.PREV.MED./A~ .

Page 2 JAPAN Dr. Yoshio KUSAMA. Professor of Preventive Medicine and Dean, Medical School Keio University Shinjuku-ku Tokyo Dr. Keizo NODECHI

Professor of Public Health Nihon University Medical School Oyaguchi-machi, Itabashi-ku Tokyo Dr. Tomio CCATA Professor of Serology and Chairman of Curriculum Committee Faculty of Medicine University of Tolcyo Tokyo Dr. Haruo KATSUNUMA Assistant. Professor of Public Health Faculty of Medicine University of Tokyo Tokyo

KOREA.

Dr. MYUNG Choo..wan Professor of Psychiatries and Dean, College of Medicine Seoul National University Seoul Dr. SHIM Sang Whang Professor of Preventive Medicine College of Medicine Seoul National University Seoul ,

NEW ZEAIAND

Sir Charles HERCUS Professor of Social and Preventive Medicine Dean, Medical School University of Otago Dunedin Dr. Gordon O. L. DEMPSTER

Director, Division of Tuberculosis Department of Health, and External Examiner in Preventive Medicine for otago University Medical School, Wellington PHILIPP:rnES •••

... W1!dO/SOC.PRBV .~. /A-2 Page :5

PHILIPPINES

Dr. Agerico B.M. SISON Professor of Medicine and Dean, College of Medicine University of the Philippines Manila Dr. Hilario IARA Dean, Institute of Hygiene and Professor and Head of the Department of Hygiene and Preventive Medicine, Colleges of Medicine, Dentistry and Pharmacy, University of the Philippines *nila Dr. Virgil.io RAMOS Dean, Faculty of Medicine University of Sto. Tomas Manila Dr. Manuel Ma. AYCAROO Professor in charge of Preventive Medicine Faculty of Medicine University of sto. Tomas !>Bnila.

SINGAPORE

Professor Ernest s. M:>N'l'EmO Professor of Clinical Medicine and Dean, Faculty of Medicine University of Mala.ya Singapore Professor T. A. LLOYD D\VIES Professor of Social Medicine and Public Health Faculty of Medicine University of Mala.ya Singapore

IW'

~ I

;

-c

VlEI'NAM

Professor Trinh Van ~T Acting Dean, Medical Faculty Univer,ity of Saigon Saigon Dr. Nghiem Lenh THIEU Member, Medical F\a.culty University of Saigon Saigon

II.

O~VERS

•

WPRO/SOC.PREV.MED./A-2 Page 4 II.

... .

OBSERVERS

City Health Officer Manila Health Department City Hall Manila, Philippines Dr. Craig S. LICHTENWALNER

United States Operations Mission to Vietnam c/o American Embassy Saigon, Vietnam Dr. Ramon MACASAET Dean, College of Medicine Manila Central University Balintawak, Caloocan Rizal, Philippines Dr. James H. MATTHEWS Adviser in Medicine College of Medicine Seoul National University Seoul, Korea Dr. Regino G. PADUA Professorial Lecturer in Hygiene and Preventive Medicine College of Medicine Manila Central University Balintawak, Caloocan Rizal, Philippines

Dr. lAuro H. PANGANIBAN •••

....

• '.

WPRO/SOC.PREV.MED./A-2 Page 5 Dr. lauro H. PANGANIBAN Dean, Institute of Medicine Far Easter"n University ManilA, Fhilippines Dr. Arsenio C. REGAlA SpeciBl Assistant Department of Health M:l.nila, Philippines

III.

STAFF

Dr. Edward GRZEl:J:ORZEWSKI Director, Division of Education and Training Services World Health Organization Geneva, Switzerland Dr. Chia-chi MA. Academic Dean National Defense Medical Centre Taipei, Taiwan Republic of China Dr. Hidetoshi SHIGA Regional Education and Training Adviser Western Pacific Regional Office World Hee.lth Organization 29th Street, Port Area Manila, Philippines Dr. Alwyn SMITH WHO Lecturer in Public Health Faculty of Medicine University of Malaya Singapore

WPRO/SOC.PREV .MED./A-3 STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16 to 29 October 1957 ITnmRARIFS OF I. AUSTRALIA .tJ.__

PARTIC~ANTS

AND WHO STAFF

PARTICIPANTS

Dr. Ronald E. MURRAY, Sydney Lv Ar Lv Ar Sydney *nila *nila Sydney Mon., 14 October Tue., 15 " Tue., 29 October Wed., 30 " 1630 0655 2210 0700 EM 240 EM 241 (T) (T)

CHINA Lv Ar Lv Ar CAMBODIA Lv Ar Lv Ar Lv Ar Lv Ar FIJI Lv Ar Lv Ar Lv Ar

Dr. Huo-Yao WEI, Taipei Dr. Kung Pei CHEN, Taipei Taipei Manila Manila Taipei Tue., 15 October

" "

0810 1120 1230 1740

CT 153 CT 150

(T) (T)

Fri., 1 November

Dr. Max MEYNA.RD, Phnom-Penh Dr. Pruoch VANN, Phnom-Penh Phnom-Penh Saigon Saigon Manila Ml.nila Saigon Mon., 14 October

" "

0630 0730 0845 1320 1620 1905 0630 0730

RC 100

(T) (T) (T) (T)

Mon., 14 October

A:F 184 A:F 193 VN 094

" "

Thu., 31 October

Saigon Fri., 1 November Phnom-Penh " " "

Dr. A. R. ElKlNIS, Suva Suva Nandi Nandi Sydney Sydney *nila Sun., 13 October

0745 0845 0730 1530 1630 0655 ~

FA 101 EM 733 EM 240 Ml.nilA

(T) (T)

M:m., 14 October

Mon., 14 October II Tue., 15

(T)

WFRO/SOC.PREV.MED./A-~ Page 2 Dr. EIM)NI'S (cont'd. ) Lv Ar

I>tI.nila Sydney Sydney Nandi Nandi Suva

Tue., 29 October Wed., ~

2210 0700 1200 2140 0900 1000

EM 241

(T) (T)

Lv Ax Lv Ar

Thu.,

October

PA 842

Fri., 1 November

FA 101 (T)

HONG KONG Lv Ar

Dr. Leslie G. Kn.;BORN, Hoogkong Hoogkong I>tI.nila M:l.nila Hongkong Dr. Dr. Dr. Dr. Lv Ar

Tue., 15 October

.. ..

1545 1815 1230 1500

PR 301

(T) (T)

Lv Ar

Wed., 30 October

PR 300

JAPAN

Yoshio KUSAMA, Tokyo Keizo NOBECHI, Tokyo Tomo OOATA, Tokyo Haruo KATSUNUMA, Tokyo Tue., 15 October

Tokyo l-anila M:l.nila Tokyo

0945 1645 :L415 2215

AF 185 (T) AF 192 (T)

Lv Ar

Wed., 30 October

KOREA Lv Ar

Dr. MYUNG Choo-Wan, Seoul Dr. SHIM Sang Whang, Seoul Seoul lI.rokyo Tokyo Manila I>tI.nila Tokyo Tokyo Seoul Mon., 14 October II

.. ..

1530 1900 0945 1645 1415 2215 1400 0900

CT 105 (T) AF 185 (T) AF 192 CT 102 (T) (T)

Lv Ax Lv Ar

Tue., 15 October

.. ..

Wed., 30 October

Lv Ar

Thu.,

october

NEW ZEIUAND

•••

WPRO/SOC.PREV.MED·/A-~

Page 3 NEW ZEALAND

Sir Charles llERCUS, Dunedin Lv Ar

Dunedin Fri., II October II Christchurch II " C1lrBtchutch

1425 1555 1700 2040 16~

NZ 108 TE 575 EM 240 EM 241 TE 516 NZ l2I

(S) (T) (T) (T) (T)

Lv Ar

Fri., II October

Sydney Sydney lohnila Manila Sydney Sydney <hr1stchurdl Chr:Istdlun:h

Lv Ar

Mon., 14 October TIle., 15 " TIle., 29 October Wed., ~ " Mon., 4 November

0655 2210 0700 0800 1510 1005 ll35

Lv Ar

" II

Lv ~

TIle., 5 November

Dunedin

(S)

Dr. G.O.L. lEMI?STER, Wellington Lv Ar

Wellington Sat., 12 October II Auckland " " Auckland Sydney Sydney tenUs. lohnila Sydney Sydney Auckland Sun., 13 October II

1600 1755 ll~

NZ 106 TE 465 EM 240 EM 241 TE 464 NZ 101

(s) (T) (T) (T) (T)

Lv Ar

1500 16~

Lv Ar

Mon., 14 October II TIle., 15 TIle., 29 October II Wed., ~ Thu., 31 October II II II

0655 2210 1700 1500 2200 0805 1000

Lv Ar

.Lv Ar Lv. Ar

Auckland Fri., 1 November II II Wellington II

(S)

... Sll'lGAPORE Lv Ar

Professor Ernest S. MONTEmO, Singapore Professor T. A. LU>YD D\VIES, Singapore Singapore tenila Manila Singapore Sun., 13 October

" II

1200

" "

PA 8;4 PA 833

(T) (T)

2105 0800

Lv Ar

Thu., 31 October

1630

VIETNAM

...

..,

. ...

WPRo/soc.P.REV.~mD./A-3

Page 4

VIETNAM

Professor Trinh Van TUAT, Saigon Dr. Nghiem Lenh THIEU, Saigon

Lv Ar

Saigon Manila Manila Saigon

Mon., 14 October

" "

0845 1320 1620 1905

AF 184 AF 193

(T) (T)

Lv Ar

Thu., 31 October

II. Dr. Chia-chi MA, Taipei

STAFF

Lv Ar

Taipei Manila

Tue, 1 October " II II

0810

CT 153

(S)

1320

Manila/Taipei

open date

Dr. Alwyn SMITH, Singapore Lv Ar

Singapore l'ibnila Manila Singapore

Wed., 9 October

1200

PA 834 (T) PA 833 (T)

" "

2105 0800 16;0

Lv Ar

Thu., 31 October

. 1\

•

'r1f!ftO/soc.!'REV .MED./A:..4

110

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDIClNE Manila, Philippines 16 to 29 October 1957 PROVISIONAL SCHEDULE

October

0730

08~

- 1000

1000-1015

1015 - 1130 Continuation Agenda 3 (gr Ol4l ) Agenda 2 (plenary) Agenda 4 (group)

r3~

·-14{)0 - 1530 Agenda 2 (group) Continuation

15~-1545

1545 - 1T30 Continuation Continuation

16, Wed. 17, Thu. 18.1 Fri. 19, Sat. 21, Mon. 22, Tue.

Tea break Agenda 1 (opening session) Agenda 3 (group) Agenda 3 (group) Agenda 4 (group)

Tea break rr

" rr

U.P. College of Medicine, Philippine General Hospital, Institute of Hygiene Continuat ion Agenda 5 (group) Agenda 6 (panel) Manila City Tea break rr rr

Agenda 3 (plenary) Continuation Continuation

U.P., Dillman, Rural Health Demonstration and Training Centre Agenda 5 (group) Agenda 5 (plenary) Agenda 7 (group) Special Interest (group) Agenda 7 (plenary) Special Interest (group) Agenda 8 (plenary) Tea break rr

Agenda 4 (plenary) Agenda 7 (group) Continuation Continuation Special interest (grrup) Continuation Agenda 9 (:fUture planning)

23, Wed. 24, Thu. 25, Fri. 26, Sat. 28, Mon. . 29, Tue.

" rr

Health

Department Continuation Tomas

Continuation Univers ity of

Tea break Santo

" "

" rr

Special Interest (group)

Tea break . rr

Continuation Agenda 9 (closing session

rr Agenda 9 (general evaluation)

-' l\

, WPRO/SOC.PREV.MED./A-4 Rev.l

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila J Philippines 16 to 29 October 1957 SUPPIEMENTARY SCHEDUIE

FOR SPECIAL INTEREST GROUPS ONLY October 25, Fri. 0830

1000

101,

1015

1130 (2200)

13;<5

1'75J

Organization of Rural Health Centres and Units (plenary session room)

Tea break

Teaching in Rural Health (Room No. 101) Teaching in Urban Health (Room No. 102 ) Cultural Studies (Room No. 105 )

Field visit to University of Santo Tomas

.... 26, Sat. Agenda 7 (plenary) Tea break

Teaching in Urban Health (Room No. 102) Clinical Teaching (Philippine General Hospital) Cultural Studies (Room No. 105) Field Visit (Quezon Institute of TB)

28, Mon.

Clinical Teachinggrocp (Visit to Phil. Gen. Hosp.) Cultural Studies (Room No. 105) Tea break Field Visit to the Tala Leprosarium

Field visit to Community Development projects

29, Tue.

Summary of Discussions, Tea break Future Planning, General EvaJ.uation (plenary session room)

Closing session (to be held any time during this period) (plenary session room)

WPRO/SOC.PREV .MED./A··5 STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16 to 29 October 1957 ARRANGEMENT OF THE DISCUSSION GROUPS

GROUP

Dr. Manuel Me.. AYCARDO Dr. Jose CUYEGKENG Dr. Haruo KATSUNUMA Dr. Leslie G. KILBORN Professor T. A. LLOYD DAVIES Dr. Chia-chi MA Dr. James H. MATI'HEWS Dr. Keizo NOBECHI Dr. Regina G. PADUA Dr. Arsenio C. REGAIA Dr. Hidetoshi SHIGA Dr. Agerico B.M. SISON Dr. Huo-Yao 'WEI

GROUP II

GROUP III

Dr. Kung Pei CHEN Dr. Gordon O.L. DEMPSTER Dr. A. R. EDIDNll3 Dr. Trinidad GOMEZ Dr. Hilario LARA Dr. Ramon MACASAET Professor Ernest S. MONTEIRO Dr. Tomio OGATA Dr. Lauro H. PANGANIBAN Dr. SHIM Sang Whang Dr. Alwyn SMITH Dr. Nghiem Lenh THIEU

Dr. Romeo Y. ATIENZA Dr. E. GRZEGORZEWSKI Sir Charles BERCoo Dr. Mariano C. ICASIANO Dr. Yoshio KUSAMA Dr. Craig S. LICHTENWALNER Dr. Max MEYNARD Dr. Ronald E. MURRAY Dr. MYUNG Choo-Wan Dr. Virgilio RAMOS Professor Trinh Van TUAT Dr. Pruoch VANN

..... WPRO/SOC.PREV.MED./A-6 ORIGINAL: ENGLISH STUDY GROOP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16 to 29 October 1957 ORGANIZATION AND PROCEDURES OF THE STUDY GROUP 1.

~'.

Agenda

The agenda is divided into nine parts with four field visits to take place on three afternoons and one morning. Beyond the proposed agenda items, provision has been made for participants to discuss topics of mutual interest which may emerge as the study progresses. 2. Discussion Groups

2.1 Division into Groups: For purposes of adequate discussion, the Study Group, which consists of 23 participants, 10 observers and four members of the secretariat, will be divided into three groups of about 11 each. While the observers are welcome to participate fully in the entire study group, it is important for the continuity of the discussion groups that attendance be regular. Should any of the observers find that they cannot attend all the group discussion sessions it is suggested that they take part in the plenary sessions only. Observers are asked to notify Dr. C. C. Ma immediately following the first session of the Study Qroup as to whether they will be attending all the sessions or only the plenary sessions. 2.2 Group Leader and Recorder: A day or two may be required for the members of each group to become acquainted with each other. It is therefore suggested that each group select a temporary leader for Agenda 2 and perhaps for Agenda 3. In addition, each group will need t'o choose a recorder who will be responsible for the recording of each group's deliberation. As soon as the discussion groups feel they are ready, group leaders may be elected. In order that this responsibility is not confined to one person, the groups may wish to change leaders for each part of the agenda. The same procedure might also be app~ied in the choice of recorders. To allow sufficient time for,translation and duplication, it is urged that group reports written in long hand be given to Dr. Alwyn Smith in the Secretariat's Room at the Institute of Hygiene, (or dictated to one of three stenographers if desired) not later than 1-1/2 hours following the' conclusion of each major part of the agenda. It is important that the reports be brief and reflect the views and trend of thought of the group for embodiment in the final report, rather than a verbatim record of every statement made. The person or persons designated by each group to report its findings at plenary sessions should have an opportunity of reviewing the group report before presentation. As these reports will be distributed to all participants and observers beforehand, the reporter for each group may wish to present only the highlights of the report or to choose any other way of presenting the points of agreement and/or disagreement of his group.

Plenary Sessions

WPRO/SOC.PREV.MED./A-6 Page 2 3. Plenary Session

3.1 Scheduling: On account of the time needed to translate and duplicate the group reports, it will not be possible to schedule the plenary session for each major part of the agenda immediately following the conclusion of the respective group session. 3.2 Organization: The plenary session will include the entire group, those selected by the groups to present their findings and a moderator. At first a member of the secretariat will nct as moderator and as the meeting progresses 7 participants may serve in this capacity. A recorder will be selected from among the participants at each plenary session to record comments and suggestions that may be put forth. 3.3 Plenary Reports: Plenary reports should be handed to Dr. Alwyn Smith as early as possible for prompt inclusion in the final report. 4. Planning Committee

4.1 Organization: It is proposed that as soon as participants are sufficiently acquainted with each other, a planning committee is organized to consist of a chairman, three members and members of the secretariat. The chairman of the committee will be elected at a plenary session. discussion group will elect a representative to serve on the committee. 4.2 Functions: Each

4.2.1 The committee will meet, daily if necessary, to discuss ways of making the study group meeting a satisfying experience. It will therefore be in a position to initiate or consider suggestions for making any changes that may be necessary. It will also discuss problems that may arise in the course of the 4.2.2 study group meeting. Matters of an administrative nature will be referred to the secretariat.

Field Visits

5.1 ~se: The four field visits are designed to provide opportunities for participants to observe the physical andmethod~gical aspects of the undergraduate teaching of sncial and preventive medicine in the University of the Philippines and the University of Santo Tomas, and their field facilities and to study some of the problems encountered. 5.2 Discussion: Time will be allowed for on-the-spot discussions at the conclusion of· each v i s i t ' , t :L,,\'-A\ 'f,~<~.,"~ .

Special Interest

Grou~s

6.1 Organization: Mere than three half-days have been provided for participants to discuss problems not included in the agenda. Those who are interested are kindly requested to refer these topics or problems to the planning committee representative of the gro up •••

•

WPRO/SOC.PREV.MED./A-6 Page 3 of the group as early as possible so that the Committee will have time to consider how these groups may be organized. 6.2 Plenary and Report: If desired, a plenary session may be held at the end of the period assigned for special interest groups. Whether a plenary session is held or not, a report from each of such groups will be necessary for inclusion in the final report.

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE Manila, Philippines 16-29 October 1957

REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./A-7 17 October 1957 ENGLISH ONLY

CHECKLIST OF DOCUMENTS DISTRIBUTED TO PARTICIPANTS . Document Number Title Available in English (E) and French (F) E&F E&F

•

WPRO/SOC.PREV.MED./l Rev.l WPRO/SOC.PREV.MED./2

TENTATIVE AGENDA RELATIONS OF SOCIAL AND OTHER SCHOOL by BEl'WEEN THE DEPARTMENT AND PREVENTIVE MEDICINE DEPARTMENTS OF THE MEDICAL Dr. H. Lara

WPRO/SOc.PREV .MED./3

THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE. THE CURRICULUM. By Professor E. Ford

E&F

WPRO/SOC.PREV.MED./4

ROLE OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE IN COMMUNITY HEALTH ACTIVITIES by Dr. Chia-chi Ma

E &F

WPRO/SOC.PREV.MED./5 WPRO/SOC. PREV.MED. /6

THE SCOPE OF RESEARCH IN SOCIAL MEDICINE by Dr. Alwyn Smith ORGANIZATION OF DEPARTMENT OF PREVENTIVE AND SOCIAL MEDICINE by Professor E. Ford THE PlACE OF SOCIAL MEDICINE IN UNDERGRADUATE MEDICAL EDUCATION by Professor E.S. Monteiro and Professor T.A. Lloyd Davies

E &F E &F

.. ,

WPRO/SOC.PREV.MED./7

E&F

WPRO/SOC.PREV.MED./8

TEACHING OF SOCIAL AND PREVENTIVE MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS IN THE REPUBLIC OF KOREA by Dr. Choo-Wan Myung and Dr. Sang Whang Shim TEACHING OF SOCIAL AND PREVENTIVE MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS IN THE PHILIPPINES by Drs. M. Aycardo, H. Lara, V. Ramos and A.G.M. Sison COMPLErED QUESTIONNAIRE ON THE TEACHING OF PREVENTIVE AND SOCIAL MEDICINE FOR UNDERGRADUATE MEDICAL STUDENTS

E&F

WPRO/SOC.PREV.MED./9

E&F

WPRO/SOC.PREV.MED./10 WPRO/SOC .PREV.MED ./10 Annex I WPRO/SOC.PREV.MED./10 Annex II

E only

, i ,

WPRO/SOC.PREV.MED./ll

•

.. WPRO/SOC .PREV .MED./A-7 Page 2 Available in English (E) and French (F) E & F

Document Number WPRO/SOC.PREV.MED./ll

Title MEDICAL EDUCATION IN COMPLEl'E MEDICAL CARE by the Committee on the Family Health and Medical Care Programme, Harvard Medical School A PROPOSAL FOR THE TEACHING OF PUBLIC HEALTH AND SOCIAL MEDICINE by Dr. K.J. Mann THE PHYSICIAN IN HEALTH EDUCATION by Dr. G. Rosen COMMENTS ON PRACTICE FACILITIES AND COMMUNITY RESEARCH OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE by Dr. John B. Grant DEFINITIONS OBJECTIVES OF THE STUDY GROUP MEETI'ING ON SOCIAL AND PREVENTIVE MEDICINE by the Secretariat A SURVEY OF THE TEACHING OF SOCIAL AND PREVENTIVE MEDICINE IN THE JAPANESE MEDICAL SCHOOLS by Professors Y. Kusama, K. Nobechi and T. Ogata and Assistant Professor H. Katsunuma

WPRO/SOC.PREV.MED./12

E&F

WPRO/SOC.PREV.MED./13

E & F

WPRO/SOC.PREV.MED./14

E & F

-! E & F E & F

WPRO/SOC.PREV.MED./15 WPRO/SOC.PREV.MED./16

WPRO/SOC.PREV.MED./17

E & F

• WPRO/SOC .PREV .MED./A-2 LIST OF PARTICIPANTS, OBSERYmS AND STAFF PROVISIONAL SCHEDULE ARRANGEMENT OF THE DISCUSSION GROUPS ORGANIZATION AND PROCEDURES OF THE STUDY GROUP CHECKLIST OF OOCUMENTS DISTRIBUTED TO PARTICIPANTS E only

WPRO/SOC.PREN .MED./A-4 WPRO/SOC .PREN .MED./A-5 WPRO/SOC.PREV.MED./A-6

E only E only E & F ~

WPRO/SOC.PREV.MED./A-7

E only

WPRO/SOC.PREV.MED./IB-l ••.

WPRO/SOC.PREV.MED./A-7 Page 3 Available in English (E) and French (F) E&F E only

Document Number

Title Information Bulletin No. 1 Information Bulletin No. 2 Information Bulletin No. 3 Information Bulletin No. 4 Information Bulletin No. 5

WPBO/SOC.PREV.MED./IB-l WPRO/SOC.PREV.MED./IB-2 WPRO/SOC.PREV.MED./IB-3 WPRO/SOC.PREV.MED./IB-4 WPRO/SOC.PREV.MED./IB-5

E&F E only E only

. ,

WORLD HEALTH

",oBGABIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

RIDIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./A-8 23 October 1957· ' ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957 SPECIAL INTEREST GROUPS

In compliance wi tb tbe wisbes of members of the Study Group, the following special interest groups. will be organized. The scbedule is so arranged that witb the exception of a few, members will not find it inconvenient to attend all the groups tbey are interested in participating. The proposed trips to tbe Serum and Vaccine Institute in'Alabang and otber places of interest have been cancelled because of lack of time and of enough participants. 1.

Organization Iof Rural Health Centres and Units Time Place Resource Persons: Friday, 25 October, 8:30-10:00 a.m. Plenary Session Room, Institute of Hygiene Members of tbe Department of Healtb, Government of the Philippines, and Dr. A. Mangay.

Purpose and Contents:

This discussion group is open to all participants who wish to discuss more in detail the organization of rural health centres or units from the point of view of teaching social and preventive medicine. The period of discussion may be extended if desired and if the rest of tbe morning does not conflict with the schedule of any other group.

•

Teaching in Rural Health Time Place Resource Persons: Friday, 25 October, 10:15-11:30 a.m. (12:00) Room 101, Institute of Hygiene Drs. Licbtenwalner, Falkland, Shu

Participants from Cambodia, Korea, Vietnam, etc. may wish to discuss with members of lCA and WHO future possibilities of internatioIll:11 o.saista.nce in thestreo.:.;,thening of teaching in social and preventive medicin~ through the establishment of rural health centres.

Purpose and Contents:

Teaching in Urban Health Time Place Friday, 25 October, 10:15-11:30 a.m. (12 noon) Saturday, 26 October, 10:15-11:30 a.m. {12 noon) Room 102, Institute of Hygiene Purpose and Contents:

WPRO/SOC.PREViMED./A-8 Page 2 PuXpose and Contents: common to them. agreement. l}.

Members from countries and areas where urban health is highly developed may wish to discuss problems The duration of these dicsussions may be extended by mutual

Clinical Teaching Time Place Purpose and Contents: Saturday, 26 October, 10:15 a.m. to 12 noon Monday, 28 October, 8:30 a.m. to 12 noon Philippine General Hospital

•

Members who are interested in disease patterns characteristic of this area and in the manner in which clinical rounds are conducted for teaching purposes, are requested to contact Dean Sison for detail arrangements. Participation in clinical pathological ~onference ,nIl be desired if one should take place on either morning.

Cultural Studies Time Friday, 25 October, 10:15-11:30 a.m. (12 noon) Saturday, 26 October, 10:15-11:30 a.m. (12 noon) Monday, 28 Octobar, 8:30-ll:30 a.m. Room 105, Institute of Hygiene

Place Purpose and Contents:

Cultural studies, or an approach to such. studies, relating to better understanding of students, patients and communities, will be discussed by this group. The period of discussions can be shortened or extended by mutual consent.

Quezon Institute of Tuberculosis Time Place of Assembly Transportation Saturday, 26 October, 10:15 a.m. to 12 noon Institute of Hygiene Transportation will be provided by tre WHO Regional Office.

Visit to the Leprosarium in Tala Time Place of Assembly Transportation Monday, 28 October, 8:30-11:30 a.m. Luneta Hotel Transportation will be provided by the WHO Regional Office.

8. Visit to Community

•

8. Visit to Community Development Projects Time

wmo/SOC •PREll .MED;/A-8 Page ,

Monday, 28 October, 2:00-5:30 p.m.

Place of Assembly: Luneta Hotel Transportation Transportation will be provided by the Community Development Co-ordinating Council LIST OF PARTICIPANTS 1.

.2.

Organization of Rural Health Centers and Units: may be interested. Teaching in Rural Health:

open to all those who

participants from CambOdia, Korea, Vietnam, etc.

Teaching in Urban Health: participants from Australia, Hongkong, Japan, New Zealand, Philippines, Singapore, etc. Clinical Teaching:

Dr. Wei Dr. Thieu Dr. Edmonds Dr. Meynard

-Dr. Monteiro Dr. Lloyd Davies Sir Charles Hercus

Cultural Studies Dr. Dr. Dr. Dr • Leslie G. Kilborn Jean M. Kilborn Wei Chen Institute Dr.Lichtenwalner Dr. Lloyd Davies Dr.Ma. Dr. Ramos

• 6. Visit to the

~uezon

Dr. Meynard Dr. Vann Dr. Nobechi Dr. Monteiro

Dr. Myung Dr. Dempster Dr. Shim

Visit to the Leprosarium

Dr. Dr. Dr. Dr. Sir

Maynard Vann Nobechi Kusama Charles Hercus

'Dr. Dr. Dr. Dr. Dr.

Dempster Shim

Tuat Murray Myung

8. Visit to Communi t;l Develo;£ment Projects Dr. KatsuntmJa Dr. Chen Dr. Wei Dr. Lichtenwalnel! Dr. Shiga Dr. Nobechi

.. WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDIClNE Manila, Philippines 16-29 October 1957 INFORMATION BULLETIN NO. 1

WPRO/SOC.PREV.MED./IB-l 16 August 1957 ORIGINAL: ENGLISH

This is the first of a series of Information Bulletins that will be issued from time to time between now and the opening date of the study group meeting. They will be circulated at irregular intervals as the need arillell. It ill lIuggested that they be read carefully and kept on file for future reference. Participants in the study group should feel free to ask any questions and to make conunents and suggestions. All correspondence should be addressed. to The Regional Director Regional Office for the Western Pacific World Health Organization P.O. Box 2932 Manila, Philip:pines Attention: Dr. H. Shiga, RegiOl;lSol Education and Training Adviser

Questions of general interest will be answered in these bulletins, others of a personal nature will be replied to by individual letters. The participants will receive Letters of Acceptance, in which are stated the World Health Organization's responsibilities with respect to their travel and per diem allowances. Regarding your travel from your normal place of residence to Manila, Philip:pines, and return, you will be provided with tickets (tourist class) via the most direct route. Arrangements will be ma.de for you to arrive in Manila not later than 15 October 1957 and to leave on the first available flight after the study group meeting. A copy of our travel order to our Travel Agents on the travel arrangements (authorized itinerary) to be made for you on our behalf, will be forwarded to you at a later date. In the event of any deviation from the authorized route of travel, the additional cost thus incurred will be at the expense of the traveller. ~re

Hotel reservations in Manila will be ma.de for overseas participants. information on this will be given in the next bulletin.

The per diem allowance at the rate of US$lO for the time spent in authorized travel, will be paid at the option of the partiCipant, either in the currency of his place of residence or in the currency of the place of the meeting; the per diem allowance while in Manila for the study group will be

;32.

,... ,

WPRO/SOC.PREV.MED./IB-l Page 2 In accordance with WHO regulations and as indicated in their Letters of Acceptance, the participants who live in the place where the meeting is held will be entitled to ;16 per diem allowance (one-half of that of other participants) for the duration that they attend the meeting. It is emphasized that the Organization is only responsible for the costs of the round trip tickets and the per diem allowances. It does not provide accident insurance to participants and will not be responsible for any expenses arising out of Sickness, injury, other disability or death of participants. Participants from the following countries and territories have be~n invited to attend the meeting: Australia, Cambodia, China, Fiji, Hongkong, Japan, Korea, New Zealand, Philippines, Singapore and Vietnam. In Annex I will be found a preliminary list of participating members. In addition, two consultants including Dr. E. Grzegorzewski, Director of our Division of Education and Training Services at Headquarters, Geneva, will attend the meeting. 'The names of the other consultant and other partiCipants will be announced later. A provisional agenda with suggested topics, proposed by this office, is enclosed. Participating members are urged to send euggestions or comments in order to provide a basis for the fullest possible discussion and a revised agenda will be issued later if required. As you may be aware, it is proposed at this study group meeting to discuss the undergraduate teaching of social and preventive medicine in the medical schools of the Western Pacific Region, with special attention being paid to the integration of the teaching of social and preventive medicine into that of clinical medicine. It is considered opportune to take stock of teaching methods and curriculum planning in relation to the problems of the Region in view of the considerable advances in medical education in recent years. Background information on the subject of the study group is desired from each partiCipating country in order to have a better understanding of the situation. It is therefore requested that participants from each country work together to produce a paper not exceeding 1500 words on the teaching of social and preventive medicine for undergraduate medical students in their country, together with their comments on plans for making the teaching more effective, if n~eded. It is further requested that the paper from each country be forwarded to this office by 9 September 1957. If the manuscript is received in time, it will be translated and mimeographed and distributed prior to the discussion. Apart from the above, a set of questions has been prepared on the teaching of social and preventive medicine for undergraduate medical students in the schools in which participants a.re teaching. It would be appreciated if each participant, or team of partiCipants, as the case may be, from a medical school would agree to fill in the items on the enclosed questionnaire (Annex II) and return it to this office by 9 September 1957. 'The brief narrative report requested in the Letter of Acceptance is not req,uired until cne month after the meeting. - 000 -

, .' ..

WPRO/SOC.P.REV.MED./IB-l ANNEX I

PRELIMlNARY LIST OF PARTICIPATING MEMBERS Australia Dr. Ronald Elliott MURRAY Senior Lecturer in Preventive Medicine, and Sub-Dean, Faculty of Medicine University of Sydney Sydney China Dr. Huo-Yao WEI

Japan (cont I d.) Dr. Toroio OGATA Professor of Serology and Chairman of CUrriculum Committee Faculty of Medicine University of Tokyo Hongo, Tokyo Dr. Haruo KATSUNUMA Assistant Professor of Public Health Faculty of Medicine University of Tokyo Tokyo

Professor of Paediatrics and Dean of College of Medicine National Taiwan University Taipei Dr. Kung Pei CHEN

Korea Professor, Director of Institute of Public Health, and Head, Department of Preventive Medicine National Taiwan University Taipei Fiji Dr. A. R. EDM:lNDS Dr. MYUNG Choo-Wan Professor of Psychiatrics and Dean, College of Medicine Seoul National University Seoul Dr. Shim Sang ,WHANG Professor of Preventive Medicine College of Medicine Seoul National University Seoul

i I

Principal Central Medical SChool Suva HOngkong Dr. L. G. KILBORN Professor of Physiology Acting Professor of Social Medicine Dean, Faculty of Medicine University of Hong Kong Hongkong Japan Dr. Yoshio KUSAMA Professor of Preventive Medicine and Dean, Medical SChool Keio University Shinjuku-ku Tokyo Dr. Keizo NOBECHI

Philippines Dr. Agerico B. M. SISON Professor of Medicine and Dean, College of Medicine University of the Philippines Manila Dr. Hilario lARA Dean, Institute of Hygiene, and Professor and Head of the Department of Hygiene and Preventive Medicine, Colleges of Medicine, Dentistry and Pharmacy University of the Philippines Manila Dr. Virgilio R. RAmS

Professor of Public Health Nihon University Medica~.SCh~ol OyaguChi-ma.Chi, Itabashi..,ku Tokyo

Dean, Faculty of Medicine University of Santo Tomas Manila

...

...,....

• tl

WPRO/SOC.PREV.MED./IB-l Annex I

Page 2 PhiliP~nes (cont'd.) Dr. nuel Me.. AYCARDO

fl II " I

Professor in charge of Preventive Medicine University of Santo Tomas Manila Singapore Professor E. S. J;K)NTErn.O Professor of Clinical Medicine and Dean, Faculty of Medicine Uni versity of Ma.laya Singapore Professor T. A. LLOYD DIlVIES Professor of Social Medicine and Public Health Faculty of Medicine University of Ma.laya, Singapore Dr. Alwyn SMITH (WHO staff member) Department of Social Medicine and Public Health Faculty of Medicine University of Ma.laya, Singapore

Vietnam Dr. C. S. LICHTENWALNER

(Observer) United States Operations Mission to Vietnam Saigon

WPRO/SOC.EREV.MED./IB-l

ANNEX II TO THE DEANS OR PRmCIPAIS AND PROFESSORS OF MEDICAL COLLEGES m THE WESTERN

PACll"IC REGION 1. Name of College

Has the College a specif'ic programme for the training of undergraduate medical students in hygiene/public health/preventive medicine/social medicine? Describe the arrangements for the academic ~ear 1957-58. Please specify the teaching done by faculty members a~ other persons, and the time devoted to the teaching of these subjects in the preclinical years, and in each subsequent clinical year.

WPRO/SOC.PREV.MED./IB-l Annex II Page 2

Has the College a special teaching unit (department, division or section) dealing with these subjects? •.••••••• If so, What is the total number of professional/technical staff?

4. How many Cluaiified -faculty members devote their whole time to academic work in these subjects?

Row many devote between half and all their time to these Slbjects?

What field work do the students undertake in the course of their training in public health and preventive medicine?

(a)

visits of observation

, -,. WPRO/SOC.PREV.MED./IB-l Annex II Page 3 (b) taking part in community health activities

6. Describe the attention paid to industrial hygiene (occupational health) training.

wPRO/SOC.PREV.MED./IB-l Annex II Page 4

7. Are there any trained medical-social workers on the staff of the hospitals associated with your College?

Do they take part in the teaching of undergraduates?

Do students carn out any home visits in the course of their clinical training?

Describe any co-ordinated teaching in curative and preventive aspects, in medicine, surgery, ophthalmology, obstetrics, paediatrics, etc.

••

~"'.

WPRO/SOC.PREV.MED./IB-1 Annex II Page 5

10.

the students get any training in medical statistical methods?

11.

Is there a college (or student) health service for the benefit of undergraduates?

Comments an~lans for the future Pleasee any comments here. If relations with the local medical and health services are not sufficiently described above, please amplify here. Do you consider the health services in your community adequate for the field training of undergraduates in public health and preventive medicine? Please describe any plans your College has for the development of teaching in these subjects. Please also describe the problems connected with recruiting suitable personnel who (with or without further training) might be entrusted with the development of such teaching.

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

STUDY GROup·' ON SOCIAL AND HlEVENTIVE MEDICINE Manila, Fhilippines 16-29 October 1957 lllFORMATION BULLETIN NO. 2

WPRO/SOC.PREV.MED./IB-2

September

1957

ORIGINAL: ENGLISH

r WPRO/SOC.PREV.MED./2

The following. working papers are forwarded for your pena.al: RelAtions Between the Department of Social and .Preventive Medicine and Other Departments of the Medical School by Dr. H. I.e.ra The Teaching of Preventive and Social Medicine. The Curriculum. By Professor E. Ford Role of the Department of Social and Preventive Medicine in Community Health Activities by Dr. C. C. toe The Scope of Research in Social Medicine by Dr. A~ Smith Organization of Department of Preventive and Social Medicine by Professor E. Ford

WPRO/SOC.PREV.MED./3 WPRO/SOC.PREV.MED./4

WPRO/Soc.P.REV.MED./5 WPRO/soc.PREV.MED./6

It is requested that these documents be brought to the meeting as reference will be mde to them during the discussions. It is now known that t~

partiCipants from Cambodia 'Will be Dr. Max

Meynard, Director, Royal School of Medicine, Phnom-Penh, and Dr. Pruoch

Vann, Deputy Director of Health Services, and from Vietnam, Professor Trinh Van Tuat and Dr. Nghiem Lanh Thieu. The New Zealand Government has informed the office that sUb'ject to confirllation, their partiCipants will be Sir Charles Hercus, Professor of Social and Preventive Medicine, and Dean of the Medical School, University of otago, Dunedin, and Dr. Gordon O.L. Dempster, Director of TuberculosiE/, Department of Health, Wellington, and External Examiner in Preventive Medicine for otago University Medical School.

•

Dr. Chia-chi toe, Academic Dean of the National Defense Medical Centre, Taipei, Taiwan and formerq 'With this office, is expected to be the other consultant to the study group. The following arrangements have been made for overseas participants: Travel. Attached is a copy of our travel order outlining the bookings made for you. Your air tickets will be delivered in October. It is suggested that participants appq for their ;passports and visas . (for ~nila and txansit i f necessary) at an early date so that they can ensure arrival at the .• 0 . ,,.:

WERO/SOC.PREV.MED./IB-2 Page 2 arrival. at' the meeting on schedule. This office is requesting the assistance. of the Philippine Department of Foreign .Af'fairs to facilitate the issuance of visas for Manila to the participants. The airlines issuing the tickets have also been instructed to assist them in obtaining the necessary travel documents. ,The cost of passports, visas, porterage and other gratuities must be paid by the participants. No excess baggage is allowed in addition to the 20 kilos carried free (tourist service) by the airline. The participants will be met on their arrival at the M3.nila international airport. Should there be any change in your arrival in Manila as indicated on the attached travel order, would you please notify this office by cable of the new time and date of arrival, the airline and f'lit",ht number before leaving your country. Hotel accommodation. Reservations will be made at the Luneta Hotel, Luneta Park, Manila. It is recommended that the participants stay at the same hotel to facilitate arrangements especially for field trips and extra-mural activities. The Luneta Hotel is conveniently located and charges are reasonable. Single rooms are available at the following rates: Air conditioned rooms:

Non air conditioned rooms:

;12.50, and ;14.50 (corner room). ;8.50, and ;10.50 (corner room). Breakfast -

Meals can also be taken at the Luneta Hotel:

;4.00; and Dinner - ;5.00. Mail.

12.50; Lunch -

Letters and cables while in Manila can be addressed to c/o Study Group on Social and Preventive Medicine Western Pacific Regional Office World Health Organization P.O. Box 29;2 Manila, Rl,il1ppines

cables:

UNISANTE

MANIIA

For

T(yo-ur--surna--m-e)

Ii' there is any other way 1n which the office can help you in your preparation for the study group, please let us know.

'WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND ffiEVENTIVE MEDICINE Manila, lhilippines 16-29 october 1957 INFORMATION BULLETIN NO. 3

REGIONAL OFFICE FOR TEE WESTERN PACIFIC WPRO/SOC;~.MED./IB-3

14 October 1957 ORIGINAL: ENGLISH

Welcome to the meeting of the study group on social and preventive medicine. The opening session will be held at 8:30 a.m. in Room 211 at the Institute of Hygiene, University of the Philippines, Herren Street, Manila. The programme for the opening session. 1s enclosed. In addition to the documents already forwarded to the participants, the follOWing have been distributed: WPRO/SOC.PREV.MED./I-Rev.l WPRO/SOC.PREV.MED./7 Tentative Agenda The Place of Social Medicine in Undergraduate Medical Education by Professor E. S. Monteiro and Professor T. A. Lloyd Davies Teaching of Social and Preventive Medi.cine for Undergraduate Medical Students in the Republic of Korea by Dr. Choo Wan Myung and Dr. Sang Whang Shim Teaching of Social and Preventive Medicine for Undergraduate Medical Students in the Philippines by Drs. M. Aycardo, H. Lara, V. Ramos and A.B.M. Sison Completed Questionnaire on the Teaching of Preventive and Social Medicine for Undergraduate Medical Students Medical Education in Complete Medical Care prepared by the Committee on the Family Health and Medical Care Programme, Harvard Medical School A Proposal for the Teaching of Public Health and Social Medicine by Dr. K. J. Mann The Physician in Health Education by Dr. G. Rosen Comments on Practice Facilities and Community Research of the Department of Social and Preventive Medicine by Dr. John B. Grant Definitions WPRO/SOC.PREV.MED./A-2

WPRO/SOC.PREV.MED./8

WPRO/SOC.PREV.MED./9

WPRO!soc.PREV.MEb.!lO WPRO!SOC.PREV.MED.!lO Annex I WPRO!SOC.PREV.MED.!l0 Annex II WPRO/SOC.PREV.MED./ll

WPRO/SOC.PREV.MED./12 WPRO/SOC.PREV.MED./l3 WPRO/SOC.PREV.MED./l4

WERO/SOC.PREV.MED./15

WPRO/SOC.PREV.MED./IB-3 Page 2 WPRO/SOC.PREV.MED.!A-2 WPRO/SOC.PREV.MED./A-4 WPRO/SOC.PREV.MED./A-5 WPRO/SOC.PREV.MED./~-6

List of Participants, Observers and Staff Provisional Schedule Arrangement of Discussion Groups Organization and Procedures of the Study Group Expert Committee on Professional and Technical Education of Medical and Auxiliary Personnel Second Report

WHO Technical Report Series No. 69

It is requested that those who have not yet reported on the teaching of social and preventive medicine in their country submit the report as soon as possible so ihat it can be duplicated and distributed. Textbooks and reference materials are available at the Library of the Institute of Hygiene, which has generously offered to make books available for study. A book list will be issued shortly. A guide map for the meeting site and a sketch of the Institute of Hygiene building are enclosed. The InstUute is about 15 minutes walking distance from the Luneta Hotel. Taxi service is easily available from the Hotel and elsewhere in Manila. The taxi rates are as follows: large taxis, twenty centavos (;0.20) for the first 500 metres and ten centavos (;0.10) for every further 500 metres; small taXis, fifteen centavos (10.15) and five centavos (10.05) for the first 500 metres and for every further 500 metres respectively. The cost of taxi fares is of course to be borne by participants. Transportation will be provided for the field visits, other than that to the Institute of Hygiene, University of the Philippines College of Medicin~and Philippine General Hospital. A representative of our Travel Unit will be available at the Secretariat's room at the Institute of Hygiene during the tea break. It is suggested that participants oontact him as soon as possible and that they bring with them their air tickets, passport and health certificate. The per diem allowances will be given at the WHO Regional Office. Office hours at the Regional Office are from 7:30 a.m. to 12:00 noon and from 1:30 to 5:00 p.m.from Monday to Friday. The participants' mail received at the Regional Office will be delivered daily to the Institute of Hygiene. For your information, the postage rates for airmail letters per 15 grams or fraction thereof from Manila to the following countries are as follows: Direct service: Austral:La China (Taiwan) Hongkong Japan Singapore Via Australia Fiji New Zealand

•

-;0.40 0.25 0.25 0.30 0.35 0.60 0.50

Via Hongk0!!fi Cambodia Vietnam Via Japan Korea

-;0 .25 0.25 0.40

Air-letter sheets •••

• WPRO/SOC.PREV.MED.jIB-3 Page 3 Air-letter sheets printed with 50-centavo stamp may be accepted for transmission to countries for which the air-mail fee as fixed in the foregoing shcedule is -;0.70 or less. Drs. Grzegorzewski, Shiga and Smith are also staying at the Luneta Hotel and Dr. Ma at the Army and Navy Club. They will be pleased to assist you in any-way possible.

....

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIRC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

•

ORGANISATION MONDIALE DE LA SANTE

MEETING OF THE STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICrnE OPENmG SESSION

8:30 A. M., 16 October 1957 Institute of Hygiene, Herran, Manila

1. ,,I'-

Speech of Welcome •••••••••....••..•••••.••... ~. E. Virata Acting President University of the Philippines

Message from Dr. M. G. Candau, Director-General, World Health Organizat~on, Geneva •.•••.........•.•••••.•.• Dr. E. Grzegorzewski Director Division of Education and Training Services World Health Organization Geneva Opening of Meeting of the Study Group .••••.•......••.••••••..••• Dr. I. C. Fang

3. ~

Director WHO Regional Office Manila Master of Ceremonies:

Dr. H. Lara, Dean, Institute of Hygiene

4. Recess

5. First Plenary Session Organization and Procedures of the Study Group Announcements

. ,,.

STUDY GROUP ON- SOCIl..L & PREVThTIVE MEDICINE 16-29 OCTOBER 1957 Place of Meeting: Institute of Hygiene Building, Herran, i!'!anila

GROUND FLOOR Room 101 Technical Staff

Room 102

Group I

Room 105 - - -

Group III

lmte-room to Institute! s j;dministrati ve Officer - \~HO

Jdministr&tive .:itaff

SECOND FLOOR Room 204-206 - - Coffee Room

Room 211

- - - Plenary Session

TOP FLOOR South EA~reme

Left side Room - -

Projection Room

South Extreme Right side Room - -

Group II

•. .4

SKETCH OF ROOMS mSTITUTE OF HYGIENE, UNIVERSITY OF THE PHILIPPINES Herran St., Manila

TOP .

FIOOR (R)

SECOND FLOOR (2 )

W.G.

1-' .,L

• _ fila //,%/.: ~ -/:/ ",///// -;/,

. \\\ ,GROUP ~_

SECRETAr , Room

Stairs

Room 105

AUDITORIUM

t--i

• f

• t ;

e. .)~0"/ffiL@ LIBRARY

,/~./~~ GROUP \~

102

GROL1ID

or FIRST FLOOR (1)

•

MANILA - - - -.........'"I!IIt. ",.fItJ.

WCRLiJ HLALTH ORGANI2.ATION STUDY GROUP ON SOCIAL AND ?REVENTlVE MEDICINE Manila, Philippines 16-29 October 1957

RLGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.?REV.MED./IB-4 15 October 1957

INFORNATluN BULLE TIN NO. 4

BOOKS The following ~~ ~ ~i~~ ~f h~oks on subjecwrelated to Social and Preventive Medicine which are on show in the library of the Institute of Hygiene. This collection is compiled frol;] works available and is not intended to be exhaustive or necessarily representative of books existing in these fields. If other books become available they will be added.

GENERAL Boek, H.E. and Boek J. K. Cannon, I. M. Chenoweth, L.B. and Morri8on, W.R. Conant, J. B. Frank, L. K. Paul, B. D. (ed.) Sigerist, H. E. Stern, B. J. SOCIETY AND HEALTH ON lHE SOCIAL FRONTIERS OF· MEDICINE COM1IDNITY HEl.!.TH MODERN S:HENCE AND MODERN MAN SOCIETY 1..S THE Pl;.TIENT HEf:.LTH, CU1TURE AND OOl4l!:UNITY MEDIC lNE f.ND HlMl.N \~Lh.RE

MEDICINE IN INDUSTRY SOCIAL l-iEDIClNE

C1uver,1. H. Donahue, Wilma and Tibbitts Eastern States Health Conference Ga1dstotl, I. Sand, R. Shyrock, R. H.

SOCI;.1 hElJICINE PLi.NNIN G THE OLDER YEI..RS THE SOCIi.!. l.ND BIOLOGICil1 CHALLENGE OF OUR i.GINS POPULI.TION THE ME.'.NING OF SOCIlu. mEDICINE THE lillVi.NCE TO SOCIi.!. IlEDICINE THE DEVEIlHMENT OF MODERN MEDICINE Wins low, G.j;, .1..

WPRO/SOC.PREv.MED./IB-4 Page 2

Wins low, q. E. Ross,

i ••

'IRE COST 0 F SICKNESS AND 'TIL!. mICE OF HEi.LTH

THE NllTIOi'ii.L HEI.LTH SERVICE IN GREAT BRIT:.IN

Ormerod and Walker Stevenson, i•• C. (Ed.) PREVENTIVE HEDICHJE

Rosenal1, M. J. Sherwood, N. P. Smillie, W ••~. Van Rooyen, C. E. Learmonth, J. Givner and Bruger Ro sena u and .i'la.xc.y Leavell, H. R. and ·Clark, E. G.

PREVENTIVE MEDICINE 1.IID PUBLIC HE:.LTH UMUNOLOGY PREVENTIVE MEDICINE ;JID PUBLIC HR.'U.TH VIRUS DISEl.3ES OF Mi..N

THE CON1RIBUTION OF SURGERY TO PREVENTIVE MEDICINE THE PREVENTION OF DISE..8E IN EVERY DuY PJi.CTICE PREVENTIVE MEDICINE

i.',D HYGIENE

TEXTBOOK OF PREVENTIVE MEDICINE

EPIDEMIOWGY

Galdston, I. Riese, W.

THi.'. EPIDEMIOLOGYjF HE:.LTH 'illE CONCEPrION or DISEl,sE EPIDE11ICS IN COLONI:.L i.MERIC.L. PUBLIC HE.:J.TH

Duffy, J.

•

Hanlon, J. J. Milbank Nemorial Fund Mustard, H. S. Prescott, S.

PRINCIPLES OF PUBLIC HE:.L'IH. lu:MINISTR..:. TroN RESE..RC H IN PUBLIC HEllL'ill GOVERI-MENT IN PUBLIC HEi.LTH SEDGWICK'S PRINCIPLES OF Sl..NITil.ilY SCIENCE ,.ND PUBLIC HE.:.LTH

Fraser

~rockington

•

.. Fraser Brockington Grundy, Fred Frazer and Stallybrass Frazer Massey, I ..

WPRO/SOC.FREV.MED./IB-4 Page 3 SHORT HISTORY OF PUBLIC HE1J.LTH NEW PUBLIC HEL..L'lli

TEXTBOOK OF PUBLIC HE.:.L'lli HIS'IORY OF ENGLISH PUBLIC HE.:.LTH av.uErl1~

'lRENDS IN PUBLIC IIE...LTH

EDUCl~TION

Grundy, F.. and Mackintosh, J.M. Oficina Sanitaria Panamericana

THE TElLCHING OF HYGIENE AND PUBLIC HE;.LTH IN EUROPE SEMlNi..RIOS SOBRE LA ENSEf.llLNZIL DE MEDICINlL PRE VENTI Vii. PROCEEDINGS OF THE FL1ST 1rmI.LD CONFERENCE ON MEDIC[LL EDUCi.. TION W.H.O. EXPERT OOMMITTEE REPORT NO. 69

CCMPREHENSlVE HEi.LTH· CiJlE Bachmeyer and Hartman, (ed.) Goldnann, F. HOPPlTii.L TRENDS 1.Nb DEVEIDlMENTS PUBLIC l'EDICl.. L Cil.RE; i>.ND PROBLEMS PRINCIPLES liN

Gunn, S. M. Hiscock, I. V. Mott, F. and Boehmer, M.I. Trussell

VOLUNTldlY HEI.LTH i.GENCIES: INTERPRETIVE STUDY CCMMUNITY HEi.ll'H ORG:l.NISATION

RUlli..L HI..1.LTH 1.ND MEDIC!LL CI.RE HUNTERDON MEDICiJ. CENTRE SOC TILL BCIEBCE-

Cartwright, D. and Zander, 1 .. (Eds) Kluckholn, C. Koos, E. L. lund, R. S.

GROUP DYNAMICS; THEORY

RESEaRCH AND

MIRROR FOR Mi.N, THE RELi.TION OF 1..NTHROPdlDGY 10 MODERN LIFE

THE SOGIOIDGY OF THE Pl. TIENT KNOWLEDGE: FOR Wlli~T? THE PLf.CE OF SOCIIIL SCIENCE IN :J1ERIC1..N CULWRE

Mead, G. H.

•

... WPRO/SOC.PREV~./IB-4 Page 4

Mead, G. H.

MIND, SELF 1.ND SOCIETY SOCIi.L SCIENCE IN MEDICINE MEDICi.L STt..TISTICS

Simmons, L.

Hill,

l ..

PRINCIPLES OF' MEDIG:.L S'li.TISTICS VITi.L STi.TISTICS IN THE TROPICS ME1.SUREMEN~

Edge, P.i.. Crew, F.,i.... E.

S OF THE PUBLIC H&.1 TH

JOURNIJ.S l'lMERIC1.N JOURNL.L OF PUBLIC HE.;'.LTH BRITISH JOURNl.L OF PREVENTIVE IdID SOCIL.L NEDICINE BULLE TIN OF HY GIENE JOURNlJ. OF MEDICl.L EDUCl.TION PUBLIC HEl.L'lB REFDRTS BOLETINA OFICINI. SlJUT••RL'. P.[.Nl'.MERICI.Nl!.

•

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

REGIONAL OFFICE fOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./IB-5 15 October 1957

Manila, Philippines 16-29 October 1957 INFORMATION BULLErIN NO. 5 Some documents concerning other conferences on subjects related to the present one. 1. 2.

Committee Reports - Conference on Preventive Medicine in Medical Schools, Colorado Springs, Colorado, November 3-7, 1952* Conference of Vina del Mar, Chile, 10-15 October 1955 SMP-l!4 - Questions suggested by the Topics of the Agenda SMP-l!20 - Summary and Conclusions SMP-l/34 - Summary and Conclusions of the Conference on Preventive MediCine, Tehuacan, Mexico, 21-29 April 1956 Boletin de la Oficina Sanitaria Panamericana, Vol.XXXVII, No.5, Noviembre 1954: La medicina preventiva en el plan de estudios medicos universitarios (Dr Edward Grzegorzewski) Boletin de la Oficina Sanitaria Panamericana, Vol.XLI, No.1, Julio 1956: Educacion y Adestramiento: Seminarios sobre la Ensenanza de medicina prevent iva International Study Conference on Undergraduate Training in Hygiene, Preventive and Social Medicine, 8-13 December 1952, Nancy: Collaboration on Teaching within the Medical Eaculty Dr Fred Grundy, Cardiff 11

3. 4.

2 _

Content of Training, its place and importance in the medical syllabus - Dr A. Stampar, Zagreb Methods and procedures in teaching of hygiene, preventive and social medicine, Dr Axel Strpm, Oslo Collaboration dans le domaine de l'enseignement, entre • la faculte de medecine et d'autres institutions, par le Dr Joseph Tomsik, Bale NORWAY - Summary description on Undergraduate teaching in Public Health, Hygiene, Preventive Medicine and Social Medicine at the University of Oslo - Information given by Prof. H. Natvig EIJR/MTPM/4 •••

3 4

EIJR/m!PM/3

*The ,

....

Report of Colorado Springs Conference, November 1952, has 'appeared in the Journal of Medical Education, October 1953 - Vol. 28, No. 10, part 2 .

WPRO/SOC.PREV.MED./IB-5 Page 2 EUR/MrPM/4 SWEDEN - Swedish undergraduate education, in hygiene and Social medicine, - Information given by Prof. G.A. Fischer Introductory remarks ITALY - Data on the teaching of hygiene in the Italian universities, by Professor Giulio Buonoroini UNITED KINGDOM - The Teaching of Social and Preventive Medicine to Undergraduates in the United Kingdom Information given by Sir John Charles FRANCE - Information collected by Dr R. SOhier, Lyon, France CONCLUSIONS

" " " II

18 -

20 22

EUROPEAN STUDY CONFERENCE ON POSTGRADUATE TRAINING IN HYGIENE, PREVENTIVE MEDICINE AND SOCIAL MEDICINE, G~teborg, 6-10 July 1953 - Ordre du jour - (unnumbered - French only) EUR/P'rPM/R/4 II

Aims and Objects of Postgraduate Training Summary of introduction by Prof. J.M. Mackintosh Methods of teaching - Summary of introduction by Prof. Fraser Brockington Content of teaching Summary of introduction by Prof. Gunnar Fischer

R/2 R/l

EUR/P'rPM/4

YOUGOSIAVIA - by Prof. A. Staropar IREIAND - by W.D. O'Kelly, Dublin HOLLAND - by Dr R. ReIlllllelts GERMANY - by Prof. Klose FRANCE - by Dr G. Petit-Maire UNITED KINGDOM _ by Prof. J .M. Mackintosh REVISED SUMMARY OF DISCUSSIONS

" II

6 9 15 18 19 22

" " " " 8.

CONFmENCE ON POSTGRADUATE TRAINING IN HYGIENE, PREVENTIVE MEDICINE AND SOCIAL MEDICINE, Zagreb, 2-7 July 1956

Copy of PRELIMINARY PROGRAMME 9.

WHO/EDUC/78 -

PREVENTIVE AND SOCIAL MEDICINE IN THE UNDERGRADUATE CURRICULUM An Attempt at a Formulation, by Dr J.N. Morris, etc. 10 • SYLIABUS •••

... I

WPRO/SOC .PREV .MED./IB-5 Page 3 10. SYLLABUS prepared by Dr Carl E. Taylor, Professor of Preventive Medicine, Ludhiana, (on request of teachers of preventive and social medicine, at a Conference held in Delhi, 21-23 March 1955) Draft Agenda for a National Conference on Medical Education prepared by Dr E. Grzegorzewski, 1955 Preventive Medicine in the Undergraduate Medical Curriculum, by Dr E. Grzegorzewski, Geneva, 1954 (Offprint from Report of International Congress of Gynaecology and Obstetrics, Geneva, 1954) Report by Dr E. Grzegorzewski on WHO Visiting Team 'of Medical Scientists to Egypt, 27 November/14 December 1955 New Doctors for a New World, by Dr E. Grzegorzewski (WHO News Letter Number 8-9, August-September 1950 Study Group on the Preventive Angle in the Teaching of Physiology - A preliminary outline of the problem, by Dr Erwin Kohn, January 1957 (MH/AS/6.57)

11. 12.

13. 14. 15.

wo rtLD

HEAL TH ORGANIZATION

REGIONAL OFFICE FOR 'IRE WESTERN PACIFIC

STUDY GRDUP ON SOCIAL AND PREVENTIVE MEDICINE

J6 October 1957 ORIGINAL: STUDY GROUP I SUMMARY OF OPII~ON

ENGLISH

(Topic

1. i

The objectives of undergraduate medical education, as given by the Association of American Medical Colleges, were discussed. There is presently still a need for a department of preventive medicine in the medical school with the ultimate objective of integr.lting its functions in clinical teaching. The role of a licensed roodical graduate in the community is to look after its medical and health care along curative, prevel1tive and promotional aspects. lhe ~Je mentation 0 f this, however, would vary depending upon the region or community in question.

(

WORlD HEALTH ORGANIZA TION

REGIONAL OFFICE R>R TIlE l,lES'IERN PaCIFIC

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

J.6 Oc to bar 1957 ORIGINAL: ENGLISH

STUDY GROUP SU}IoUI.RY

OF OPINION

(Topic 2) DEFINITION

The Group accepted with certain minor alterations the definition of social medicine, hygiene, public health, preventive medicine, social and preventive medicine, comprehensive health care and comprehensive medicine as listed in "Defini tio AS II WHO/SOC. PREV.MED./15.

The Group omitted the precise definition of health care and implied that the term must be umerstocd in the context it is used. The Group considered the subj ect in J-\genda 2 and discussed 2.1, 2.2, rod 2.3. Under 2.1, the Group after a fairly lively discussion defined the objective of undergraduate medical education to produce a sufficient number of practitioners of comprehensive medicine to supply the needs 0 f the co un try • While at the same time realizing the need to provide personnel who will ultimately be engaged in research, medical teaching and the various specialties •• There was a discussion on the methods to ba used to attract men for research work and some members were of the opinion that research woriers would b:3 attracted fairly early in the undergraduate stage of their education, while others were of the opinion that research workers am teachers usually come from graduates who after a period of practice, in hospital or in general practice decide to take on an academic career. 2~2

Discussion on the objective of the teaching of social am preventive medicine.

(1) To make the medical undergraduate actively interested in the social needs in respect of the medical services which the country can offer and the importance of the social function in the aetiology, distribution, care, prevention and treatment of diseases. , (2) Because of .~

STUDY GROUP I Page 2 (2)

1.6 Octo ber 1957

Because of thE) stride of development of some of the countries in this arEla, the do ctor on quali.fYing has veJ;'{ often to function as a public-health at' ficer dealing with social and preventive aspects of disease and hence requires certain basic skills in the practice of public health. The Group also wished to stress there is a need to make social mE)dicine and public health more attractive to the medical students.

(3)

2.3 'Ihe role of the physician in the conmunity. There was an interesting discussion on the actual connotations of the term physician and i t was decided to define it as a medically qualified person practising his profession with the same meaning as the French equivalent of "Medecin." The Ci,roup defined his role as 0 ne who is respo rsible for the maintenance of opt:iJnum level of health in the conmunity. To this end, his role must be a positive one which is prima.r~ the promotion, conservation and restoration of health. The Group also emphasized, because doctors tend to forget, that he is a citizen with civic duties and rights obose responsibilities are even greater in view of the specialized knowledge he possesses.

•

. .. WORLD HE1l.1TH ORGANIZATION ,REGIaH.L OFFICE FOR

THE WES'lERN PACIFIC

MID

S'IUDY GROUP ON SOCIAL PREVENTIVE MlIDICINE

16 October 1957 ORIGIN1.L: ENGLISH

STUDY GROUP III REPORr

ON AGEND1.. 2 2)

(Topic

IntroductoEY discussion on the teaching of social and preventive medicine 2.1 - What are the objectives of the undergraduate medical education? Undergraduate medical education should have a fundamental objective, which should be the same for all countries, should aim at imparting a basic IOOdical education, and should comprise both the preventive and the curative aspect of nEdicine; it may have a secondary objective adapted to the con:litions :in any country in particular. 2.2 - What are the obj octives of the teaching at social and preventive medicire ? The teaching should impart principally the spirit and the philosophy of social and preventive medici.re ; it should adapt itself tot he condition> prevailing in any particular country; it shoul:l require a thorough grounding in clinical rredicine; and in the graduate lvvel it should prepare spl cialists for government service in underdeveloped countries. 2.3 - What is the role of the phySician in the comnrunitl? The physician should satisfY and promote the moo.ical and heal th needs of the community; and should teach and lead in the health education of the family and the community.

STUDY GROUP In li.NNEX I

RESUME OF THE ROUND-TdBLE DISCUSSION OF GROUP III WHO ffiEVENTIVE AND SOClM. MEDICINE STUDY GROUP

16 OO'lOBER 1957, AT 1400 HOURS DR. MUR..'tl~Y was elected chairman on motion of Sir CHJ'.RLE'.'3 BERCUS and seconded by DR. KU500... Upon suggestion of DR. GRZECDRZEiI6KI and awroved by the chainnan, DR. RAMal was chosen as the recorder. Topic discussed: i.genda 2 Introductory discussion on the teaching of social and preventive medicine.

DR. ICIiSL'l.NO DR. MEXNl.RD

There is not enough social and preventive medicine coreciousness among our graduates. Preventive and social medicine is given insufficiently in Cambodia because W9 are very new in the field of med:ical education but in our plans we are giving more emphasis to this subject. Emphasis varies in different countries because of different condition:;. We have two objectives: edUCational and vocational. The former is important to undergradua. tes, the latter is emphasized in the intern years in . which it is compulsory. We should have two spheres of objectives - one fundamental for all medical schools and another transitory depending on the circumstames of each school; f or example, one country may like to pre'pare the leaders first and later practitioners. ~

DR. KUSilM1.. SIR CH1iliLES

DR. GRZECDRZEWSKI -

ICASraNO

doctor is useful to his community if he knows its problems.

DR. RlIMOS

Many years ago, the study of preventive medicine was oriented main~ towards the prevention of infectious diseases. Nowadays, the tendency is towards the prevention of diseases in general. Thirty years ago, W'l were trained also in the prevention of infectious diseases, nowadays, the most important aspect is industrial hygiene principally toxicology, because 0 f the increase in industrialization_ In ~ustralia, there has been a decrease in the incidence of diseases like gastro-enteritis and tUberculosis.

DR.

KU~

DR. MURRl..y

DR. <1ZREOORZEWSKI , .,

STUDY GROUP III .H.NNEX I page 2 DR. GZREGORZEWSKI -

In some countr:iles, tha;re had been early SJB cialization, as for example, en child health.. In Egypt, there was a tinE when the question w as whether to prepare doctors for rural work differently from doctors who were going to practice in the cities. I believe that it is better to have one type of medical education for all doctor& vie should aim towards the preparation of a basic doctor. ~#.3 should not consider specialization in undergraduate years. Fundamental training should be the same for all unde:r-, graduate students. One of the important points is to d etormine what part of the subject matter should be retained in the undergraduate years and what part should be transferred to the graduate level. What is important is the spirit and the philosophy of preventive and social medicine. He are over-emphasizing the factual contents of th:; curriculum and underemphasizing the spirit and philosophy of the subject. Is it the idea to adopt this for 8.11 under-graduate students? Yes. We should like to knovi what the representatives of Vietnam and Cambod:iJl. think about this since they are nO,1 in the period of construction of their medical schools. Up to now Cambodia is mora in teres ted in the curative aspect of medicine. Later on, T!16 may emphasize the preventive aspect. Is it a good method to orient the whole study of medicine towards preventive medicine? The average student is thinking in terms of the curative aspect of medicine. Up to ·tbrld War II, we thought principally of environ.. mental s ani tat ion but after the war, our outlook has changed. What is your aim, more preventive or lTD

CHI.RIES

DR. MURRfi.Y DR. RIlMOS

SIR CHI.RLES

DR. V.ANN DR. MURRI.Y DR. GR2ECDRZEWSKI -

DR. VANN

DR. MURRiJ DR. MYUNG

DR. MURRAY DR. KUSAM..

re curative?

Future doctors should have fundamental knoW!. edge of preventive medicine. The spirit of preventive medicine shouJd be imbued in them. DR. VI.NN -

STUJ:[ cm.OUP lIT

•• IHlEX I P:::ge :3

DR. \rum

My personal experience is that when I bec<.mo interes ted in preventive llfl dicine I lost interest in curative medicine. ... We need specialists in public health like you. According to one repo rt issued by the WHO the dec tor should be prepared to practice both preventive and curative mtdicine and aware of the psychosomatic or social factors affecting practice. (He referred to three clinical cases in which the treatment at a~ stage had some preventive aspects). ~ doctor who pays attention only to the curative aspect of a disease does no t de::erve the name •. A doctor is more useful i f he is alerted to the

DR. KUSJ.Mi..

DR. G2.REGORZEWSKI -

DR. ICASIANO

...

conditions existing in the family 111. d in the community. 111is is the kind of physicians we are trying to develop.

DR. MURR.iJ.Y DR. Vl.NN DR. KUSAMiI. ...

Your idea is tha t of a doctor well-trained in comprehensive roodical care. This is good in theory, but cm it be carried into practice? We should imbue in the undergraduate the proper spirit. In Manchuria, many years ago, goiter was very prevalent but since we knew that it WaS due to lack of iodino in the water, we solved the problem. 1. country that has a new medical school like Cambodia,

DR. MEYNi.RD

what principlos should guide the teaching of preventive medicine and how mu.ch~ The aim at the beginning was to train undergraduates for preventive medicine only. In under-developed countr:ie s there should be more emphasis on preventive medicineo

SIR CHl.RLES

I support that doctrine absolutelyo Donlt you think that there should be postgr~duate training for specialists and government officials who are going to take care of the public health? There should be no separation between preveotive and curative medicine. ~ve can have people speciaJ.ize in certain phases of preventive roodicine, like the administrative and medical phases, as in the training given to government heal tll officials" but even these doctors should ;cot C'i:::a:::gard e n .f.ire4r clinical llfldicine. I believe any specialist in preventive medicine shotili have had before a thorough grounding in clinical medicine. DR. MUHR.'l.Y

DR. MEYN.'.RIJ

DR. GlREGORZEWSKI -

~JnillX

SXUDY GROUP III I Page 4 .~ doctor practising preventive medicine can help immensely in the application of preventive llEasures.

DR. MURRA.Y DR. MEYN:JO.D DR. GZ.REOORZE!t5KI -

I fully agree on increasing the emphasis on preventive medicine for government doctors.

There were very interesting studies on this point in Vietnam. Can we hear from the representatives from Vietnam? Preventive oodicine is given in the fifth year. We have in Iietnam a school for health technicians in which the requirement for entrance is a bachelor's degree. Formerly we follovsd the French sys tern. We are now at the cross roads and we are trying to adopt the systems used in the Philippines, United States, Japan, etc.

DR. TU1i. T

1530 - 1545 (15 DR. GRZEOORZFl«<3KI DR. ~N

minutes tea break)

The 0 bjecti ve 0 f undergraduate medical edUCation should be to make of the doctor a better future doctor. There is a school in Cambodia for government health officials in which preventive medicine is studied for four years. 118 have also a medical school. Our problem is whether to transform the school for government health officials into a school for health technicians.

DR.

KUS~.

In .England and in Soviet countries, there was a time when two different kinds of doctors were allowed to practice. In India there are no more schools for licentiates in medicine. Everybody has to get the doc tor's degree. If the idea in Cambodia is to train two different kinds of doctors, men they have sufficient doctors, ther" will be confusion. ~ are planning to rep_aa the school. for health officials with a school for health technicians, but the situation in Cambodia is rot the same as in Vietmm or Bunm.

DR. GlRECDRZEWSIa: -

DR. KUSiIMA

IIR.

MEYNi~RD

DR. GlREGORZEWSKI -

vie must not try to tell Cambodia mat to do without knovn. ng Cambodia. DR. lCi.SIi.NO

. S TUnY GROUP III ;.NNEX I

Page DR. IC~llNO

The role of the physician in the community is to satisfy or proIOOte the madical an;i health needs of the comnnmity. He must know clinical and social madiaLne. The physician of today is different from that of years ago. The physician should be the leader in his field. .. According to two internists, it is essential to inculcate health principles in the undergradunte students. It is too natural func tion of the docto r to be the 1s ader in the health education of the patient am his family.

SIR CHARLES

ffi.

GZREGORZ~KI

SIR CHARLES

In hippocratic writit€s there are many references to this roJs of the doctor. The role is to cure, to lead en d to teach. And to mobilize the resources that can help in the conservation of health. He should be the co-ordir..ator of the health resources of the community. In the lvorld Conference on Medical Education held in wndon the consensus of opinion waa that tke undergraduate should be prepared to becoma a basic doctor. ~

DR. GRZEOOIrlElll3KI SIR CHARIES

DR. GRZECIlRZEWSKI DR. RllMOS

DR.

GRZEGORZ~I

.after graduation, th8n he can prepare himself for roodical practice, for research or for teachillga Regarding this basic doctor, do you plan to shorten the curriculum? We will come to that when we discuss the curriculum-

DR. MEYNli.RD DR. MURRt.Y

SIR CHARLES

- 'Since we have discussed all the points in the agenda, may be we can now read the papers on these points.

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PRE.VEm'IVE MEDICINE STUDY GROUP I SUMMARY OF OPINION

RIDIONAL OFFICE FOR THE WESTERN PACIFIC

18 October 1957 ORIGINAL: ENGUSH

(Topic 3) Curriculum content and methodology of teaching social and preventive medicine 3.1 The detailed curriculum of social and preventive medicine should be determined by the local conditions in each ar~a. ,

The spirit of the curriculum should be pointed toward more realistic, practical approaches to social and preventive medicine in the clinical years. The "traditional" aspects of public health must be retained in the curriculum, with varying amounts of emphasis and time in different schools, because: (a) Every practitioner has contact with public-health problems. (b) Graduates often perform environmental sanitation duties as they practise in the rural areas of most countries. (c) Epidemiology is of continuous interest and importance. (d) The historical aspects of preventive medicine should be required knowledge of every graduate. (e) Preventive medicine is a discipline Which can serve as an integrating force for all other disciplines in the basic science and clinical science fields. (f) The social and preventive medicine curriculum provides an opportunity to stress the normality of the human at a critical period in the undergraduate education programme. The curriculum should cover environmental sanitation, public health, epidemiology, statistics and biometry, normal development, personal health services (family planning, well-patient CliniCS, health clinics, medical economics, medical administration, and social welfare services. Ideally, biometry should be incorporated into the pre-professional years, if there is adequate control over curriculum content. Otherwise, biometry should be taught in the pre-clinical years, with emphasis on vital statistics in the clinical years. Whenever possible ••• J ..

STUDY GROUP I Page 2 -~.' )

Whenever possible, normal growth, psychology, and sociology should be included in the pre-clinical didactic preparation, followed by practical application and integration at the bedside. It might be desirable to incorporate additional preparatory work in the social sciences into the pre-medical curriculum.

3.2 The precise duration of individual courses must be determined by 41) the country conditions, and (2) by the extent to which other faculty members integrate the concepts of social and preventive medicine into other portions of the medical curriculum. Ideally, the programme should be spread throughout the entire medical curriculum, with increasing emphasis toward the last clinical year or years.

3.3 Teaching methods must take into consideration the social climate of the student, the social climate for the Department in the medical school, and the latitude of techniques available. Didactic, audiovisual, conference, seminar, laboratory, ward round, joint ward rounds, field trips, and home visits are desirable methods.

3.4 The clinical approach to teaching can be incorporated by the faculty in social and preventive medicine at ward rounds, joint ward rounds, seminars, and case-work problems. The most natural and informal atmosphere is preferred to the dramatic, staged scene for integration activities between departments. The role of the physician as the leader and originator of the medical service team should. be emphasized. to encourage the development and growth of the paramedical services desired in many countries. The process of evolution leading to an id.eal social and preventive medicine curriculum is a slow one, in which the faculty must recognize the importance of parallel community d.evelopment and. general public ed.ucation. The session on the morning of 18 October opened with a further explanatory statement by Professor K. Nobechi on items 3.3 and 3.4. The group then proceeded. to discuss items 3.7 and. 3.9.

3.7 There was general agreement as to the need for practical instruction in health centres,or their equivalent,where students can participate actively in the social and preventive work of the community under adequate medical supervision. The value of having the officers of the ~ealth department appointed to the teaching staff of the medical school and in turn the university members of the social and preventive medicine department being recognized officially by the health department was 'emphasized.. Ad.ditional method.s of instruction were discussed. and. the value of field. surveys carried out during vacations particularly by senior medical students was endorsed.. An exhibit of such a survey by Singapore medical students was favourably commented on. It was felt that this method was of particular value in countries where environmental sanitation is still primitive.

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE STUDY GROUP II SUMMARY OF OPINION (Topic 3)

REGIONAL OFFICE FOR THE WESTmN PACIFIC 17 October 1957 • ORIGINAL: ENGLISH

Curriculum content and methodology of teaching social and preventive medicine Since the new Group II was increased by half of the Group II, there was a need for reporting yesterday's point of views concerning agenda item 2 of each group. As a result of this procedure, the opinions of the two groups were adopted as complementary.

The different elements of the curriculum intended to strengthen preventive medicine teaching should be introduced at all stages of medical studies. Although the organization of education preliminary to studies of basic medical sciences (i.e. anatomy and physiology) varies in different countries, it is essential that all students be given a broad libe~al education at that stage, in addition to the natural sciences usually required from the candidates to medical studies. Furthermore at this stage, Which could be called pre-medical, the premedical, the student should be taught the elements of social sciences, psychology and those elements of mathematics Which will help him to cope later with medical statistics. The teaching of biology normally done at this stage should be oriented rather towards human biology and including some notions of social biology. The next stage of medical studies usually called pre-clinical embraces the study of basic medical sciences (anatomy, physiology, biochemistry, pharmacology, pathology, microbiology) and the introduction to clinical nedicine. It is suggested to greater Dr lesser extent that the following elements be included at this stage: a) b) c) d) e) f) Biostatistics Human genetics Nutrition Environmental hygiene, particularly as related to microbiology. Men tal health History of health. Most of these •••

STUDY GROUP II

Page 2 Most of these elements should be included in the regular course of different subjects and not necessarily be taught in the department of social and preventive medicine, but it is necessary that they are taught somewhere during this stage.

,.2 ,.4

In spite of the slight difference in the percentages of hours devoted to the teaching of preventive medicine in the various schools, the average total number of hours of preventive medicine teaching is around 200 hours. The clinical approach in teaching social and preventive medicine could be incorporated by appointing clinicians who have u )reventive approach; and public-health specialists with clinical skills; by regular clinical social pathological conferences; by the influence of the dean in obtaining co-operation between different departments and the department of preventive medicine. All clinical departments can take part in stressing the prevention and social aspects of diseases. Also members of departments of pre-clinical studies may contribute by stressing the preventive aspects in such subjects as pharmacology, physiology, anatomy, etc.

,.5

These three items being very closely related, all participants were requested to relate their experience on any or all of these points. From the experiences in various schools it might be stated: (1) that some form of practic or exposure of the medical students to practical work in public health should be arranged; (2) that the most appropriate time would be determined by each school; (,) where health centres administered by various agencies are used for teaching medical students, the department of preventive medicine of the university concerned should have some influence on the type of work being performed so far as it influences the training of students.

--"

,.10

It was generally agreed that this important item should receive more consideration. It is an important method of teaching preventive medicine.

--- . WORLD HEAL T;i ORGll.NI2Jl.T IOll STUDY GROUP ON SOCI1~ REGION~u.

OFFICE

FOR

THE loJES TERN PACIFIC

19 October 1957 ORIGHlil.L: ENGLISH

AND PREVENTIVE MEDICINE

STUDY GROUP I SUMil'dtY OF

OPINION

(Topic

Organization of. Department. of Social and Preventive Medicine

. 4.1, 4.2 and 4.3

There was complete ~reement that the functions of the Department of Social. and Preventive Medicine differed in no way froin those of any other University Department thus they include teaching and research and advice where required to the University and to the community which it serves. In virtue of the great change in progress in medicine in connection wi. th its social and preventive functions, the Department must meantime assUllE an active co-ordinating and stimulating function throughout the whole University and medical school. There was also unanimity that these functions could only be carried out by a well-staffed independent department and that in under-developed countries the need for such a department was the mre urgent· as the future doc tors must ever he the foundation; of any national medical service. Both integrated and continuous' instruction throughout the medical course were considered to be essential.

4.4 A lively discussion took place on the staffing requirements of the Department of Social and Preventive Medicine. It became clear that the situation· depended to a large extent on the state of development of the medical services of the particular country. One general principle however emerged that whatever be the background of the staff, quality was of supreme importance. \Vhile this requirement applied to the whole staff, it was felt that it applied particularly to the professor who must be acccepted by his colleagues and by the student body as of consultant status. Without this recognition the future development of the subject in the medical school must suffer. It was agreed that the f.ledically qualified staff should include in addition to the professor and one or more whole-time teachers, a number of part-time lecturers drawn from the various fields enumerated in 3.1.

4.5

There was complete unanimity as to the need for a nucleus of wholetime staff as in any other University Department. The Group was imPressed by the far-sighted policy of tho Govorruoont of Japan advised by their Medical Education Committee in establishing not only wholetime professorates

STUDY GROUP I Page 2 time professorates in all the medical schools in Social and Preventive Medicine but, in $0% of the 46 medical schools, two professorial departments have been created one in environmantal hygiene the;Jther in.the personal ill . services. No school in Jape.n has less than.. tID pro{es'sors' -. social and preventive medicine whether in Clne department or hlo. One school has three whole-time professors. The discussion revealed that in only one country represented at the Conference was there no who1etime staff. -

4.6

Some difference of opinion emerged as t·o the type of training required for the whole-time members of staff and particularly as to the Professor's educationol b~grouoo. Some considered that his experience in clinical medicine should entitle him to cClnsultant status in this field, others that some practical experience in the general practice of medicire inaddi ti.:lnto post-graduate trainingirl public-health prac~ tice and administrdion would provide the necessary clinical insight. il11 agreed as to the need for teaching a hilUy in all members of staff and methods of training in teaching method as carried out 'in the Harvard School of Public Health were favourably commented ono. The important question of recruitment of medical staff ,,111S discussed and in consequence the fundaJTE;nta1 economic considerati.ons underlying all considerations of University staffing arose. Attention~was drawn to the fact that in the University of the Philip-

pines the Jepartrrent of Social 2nd Preventive Medici."le in the College of Medicin~. and th~ Institute or Hygiene, twelve additional medical appointments had been made without difficulty within the last three years. It appeared that as in Japan the Government of the Fhilippines advised by a Medicnl ani National Economic Committee had realised the importance of high qunli ty recruitment and had raised the salitr.iesof the staff with this encouraging result. No dissenting voice was raised'to the prindp1e that the vJorkm?n was worthy of his time and that the salaries of the members of the Staff 6£ th0 Dep:<rtmon:t of S:5cio1 and Prevontive Medicine mU!>t Gqu~.to~lith ,those of their colleagueS in tm clinicn1 dop<>rtn:;nts.

•

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND HlEVENTIVE MEDICINE

REGIONAL OFFICE FOR TEE 'VlESTERN PAC IFIC

19 October 1957 ORIGINAL~

ENGLISH

STUDY GROUP II SUMMARY OF OPINION (Topic 4)

...

Organization of Department of Social and Preventive Medicine It was decided to deal with Agenda 4 this morning - 4.1, 4.2 and 4.3 before the break and 4.4, 4.5 and 4.6 after, and not to continue during the afternoon.

4.1

Function of the Department of Social and Preventive Medicine. (a) General agreement was reached that three complemntary functions exist: teaching, research and service. The majority considered that teaching was the primary function, but some discussion took place upon this point. One view was expressed, for example, that research might be considered more important at least in the amount of time and money expended. There was a live~y discussion regarding the balance of the three components and it was generally agreed, once again, that local conditions would determine their relationship with each other. (b) The co-ordination of the teaching with other departments in the medical school, the development of the social medicine atmosphere among both staff and students seems to be an important function of the Department. Either as a direct function or through its contact with the social, medical and public-health services, the training in at least some aspects of ancillary workers (almoners, public-health nurses, sanitary inspectors, etc.) was generally considered a necessary part of the Department. The varying degrees of actual service rendered the public by a social medicine departr.lent was dealt with at some length. Conflicting views were expressec1 on this and in particular, reference was made to the necessity. for a balance between applied and fundamental research. The maintenance of this balance should be one of the main concerns of the departmental head. It was also mentioned that various research projects have value in that they give direct public service. All agreed that direct service was necessary but that there necessarily exist considerable differences in the amount of service.

(c)

(d)

4.2

(a)

All .••

STUDY "GROUP II Page 2 4.2 (a) All agreed that a separate and independent department was necessary and most felt that it should be a department within the medical school. Two basic reasons were given for this decision. First, however well developed were the preventive and social aspects in each department, there remained the necessity for a co-ordinating body, one which covers, examines and decides upon the total picture. The second was, that though the clinical department might be actively interested in and valuable sources of information regarding for example epidemiological problems, the Department of Social Medicine could most usefully act upon the in:f'ormation received, this being their specific responsibility.

...

(b)

4.3

It was considered by the Group that both integrated and continuous teaching involving other departments and that separate and independent instruction~re necessary in those subjects which could not be dealt with otherwise. The use of team work in clinico-social, warorounds, study groups, and the cross fertilization between departments was practically unanimously commended.

4.4 and 4.5 (a) These two agenda items were dealt with together. First, various representatives described the personnel of their own departments. Factors determining both the total strength of the department and the relative number of full-time and part-tice personnel were:

(1) Size of school and number of students (2) The scope of the curriculum, i.e. how much dealt with by the department (3 ) Whether or net the department deals with post-graduate work (4) The amount of research envisaged and the quantity of direct service rendered.

Other factors were the stage of development of the department and the degree to which clinical and other departments have developed along preventive lines. Finally and of overriding importance was the availability of adequate personnel and the funds to finance the department. An absolute minimum agreed by the whole group was one full-time " departmental head. Further either full or part-time assistance who could provide not only specific assistance, but for temporary or permanent replacement of the head. The services of profeSSional and technical assistants particularly in the subject of biostatistics were considered essential but not necessarily full time.

4.6

(a)

Basically •••

•

STUDY GROUP II Page 3

4.6

(a)

Basically the training of personnel for a Social Medicine Department should be achieved by

1) Working in the department or

1 (b)

2) 3) 4)

The ac~uisition of special skills in other departments In formal post-graduate training in preventive medicine Teaching training in the subject as being conducted at the Harvard School of Public Health.

Finally the Group or at least some of the members suggested the essential ~ualities in a head of a Social and Preventive Medicine Department. They were -

2) 3)

(4)

Experience in teaching Experience in research Sound academic record, i.e. acquisition of appropriate postgraduate degrees Personality, enthusiasm for teaching and respect of other faculty members.

I ...

( ,

.!(

WCR!lJ HE1,.LTH OR1i.NIZATION STUDY GROUP ON SOC:uu. AND PRE VENTIVE MEDICINE

REGIONAL OFFICE FOR THE WESTERN PACIFIC

22 October 1957

ORIGINAL: STUDY GROUP I

ENGLISH

SUMMARY OF OPINION (Topic :

......

Relations between the De departments of a medica

of Social and Preventive Medicine and other

5.1 ~

J:he Group heard its members describe relations between Departments and personalities which vary from cordial co-operation to the extremes of departmental autonomY and isolationism. (The examples of good relation" shira are listed in 5.3). In general, clinical faculty members demonstrate good co-operation to the students at bedside consultations and during routine administration of ideal patient care. Every school had one or more kind of clinical conference centered on the patien~. A lesser number and variety 0 f co-operative urx:J.ertakings exist in the lecture programme. Some joint research projects are being conducted. Some schools have active leadership from the Dean or Senior faculty Which promotes co-operation in administrative matters affecting the medical student. The Group noted, realistically, that ever,y faculty had some members who preferred autonomY, or who were current~ unfriendly. Despite the presence of such relationships, the medical student probab~ graduates with an adequate comprehension of the interdependence of the various disciplines. It is desired that the student should gain much more practical experience and personal appreciation of the integrated approach to the profession. The Group sought a positive rather than a haphazard solution to this problem as it discussed agenda 5.

The Group agreed tha t the fundal1l3 ntal requirements for co-ordination must be determined in every case after a careful study of the personality factors extant in a faculty. The cawe for non-co-operation probabli is a personal psychological one. Ideally, a common spirit of approach to school problems is desirable. 'Ibis team mrk might be secured more readi~ if the faculty has a common training experience from the past. The role of the Dean in securing co-ordination was emphasized. It would be desirable to have active leadership from the Dean, or someone with adequate authoril. The Group notes that all Deans do not have adequate authority. uch leadership might initiate a comnon study whose purpose was to establish .!: programme Which would InClude e inds of events lis red in 5.2 a, b, and c. The programme also might include plans for oompulso!j'" common study groups among the less

ffiC,

enthusiastic

facul~

STUDY GROUP I

Page 2 enthusiastic facul4Y members. More frequent faculty meetings might be reqp.ired in some schools. Foreign training might be required to alter the attitude of some facuJ.tw members. Attendance at more conferences such as this would be desirable. In addition to these recommendations, the Group heard the following concepts recommended by those who had successfully tried them. (a) (b) (c) (d) faculty pr08lOtion boards lectures qy basic scientists during clinical years extensive use of clinical specialists in lectures b.r other clinicians more social activity among the faculty

5.4

Responsibilities of the Departmant are-

1. Teaching Research Advisory 3. 4. Co-ordinat ion 5. Service 6. Catalytic 2.

) ) ) ) )

(Students (School (Communitw

'oJORLD HEA.LTH ORGAN:JY.A.TION I

REG IONAL OFFICE FOR THE "WESTERN PACIFIC 22 October 1957

STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE STUDY GROUP II

ORIGINAL:

ENGLISH

SUMMARY OF OPINION (Topic

Relations between the Department of Social and Preventive Medicine and other departments of a medical sChool 5.1 "~

The relations exist in each country to some extent, but vary in types and quantities due to the historical development of their medical education system, the informal friendship of the head of the department and the policy of the dean of the medical college. The group thinks informal co-ordination should be added as item (d) in addition to the formal co-ordination of items (a), (b), and (c). (a)

Integration of courses can be organized between the department of social and preventive medicine and various related clinical and pre-clinical departments without· a t:lajor cha-llge in their original courses. But it is advised that this integration should be carefully scheduled towards sound teaching and should be selective for a specific course, not for the whole courses. A definition of "integration" was given and di. scussed. It was pointed out that "integration" may: fragment individual courses. Three disadvantages of this integration were mentioned. These were (1) to lose spaced repetition, (2) to discourage students from doing their own integration, and (3) to disintegrate individual courses. Joint seminarsware considered valuable, however. These were held to include "gr a nd rounds" and clinico-social-pathological conferences. Combined appointments - the group was not convinced that joint appointment has much to offer, except in so far as we cannot always appoint full-time personnel. Stress was placed on the importance of social and preventive medicine department teaching the relative social value of therapeutic procedures.

"If'

(b)

These was a difference of exchanges of services between old and new departments. Old department can offer some special service, such as epidemiological and statistical consultation to other departments. At the same time, the department may ask some personnel of other departments for the consultation of field social medical •••

STUDY GROUP II

Page 2 social medical care in the community. In new departments, it needs to gain ac!ceptance.There is ignorance in other departments of types of service which the department of social and preventive medicine can offer. Makes it necessary for the department to develop definite service first. (c) (d) Joint study is accepted as necessary. Informal co-ordination between inter-departments is also very important through the meetings in which heads of departments can get together to talk and to drink for serving better friendship. 'I

JI II

5.3

Through curative medicine we have an inherently attractive route for the presentation of social medical teaching. We should also show preventive roles of therapeutic procedures. We consider the fi~e levels of prevention tocperate in clinical medicine as well as in public health. That is: health promotion, specific protection, early recognition and prompt treatment, disability limitation and rehabilitation. Social medicine has many areas in which integration is not necessarily requ1red. We must not exaggerate the importance of integration. We have our own course to develop. Must beware of equating social medicine with indigent people.

5.4

The group wished to amend the sense of this item as published in the agenda. It wa3 proposed to discuss the item using the word "integrated" in its usual sense and not in the sense of any specific type of integration. The responsibility of the development wan to present to students the social implications of the practice of medicine and the occurrence of disease. To some extent this was achieved by formal development of a separate course in the department of social and preventive medicine, but it also involved some participation in clinical teaching.

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WEST1!RN PACIFIC

25 October 1957 STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE ORIGINAL: ENGLISH

STUDY GROUP I SUMMARY OF OPINWN

Practice facilities and community research of the Department of Social and Preventive Medicine 7.1 ALL facilities of the community should be available for the use of medical schools. "Facilities" include rural, urban, and student health centres, chronic disease treatment centres,mental health centres and hospitals, and the statistical, evaluative, and planning services of the government.

The group decided to withhold major consideration of the utilization

of rural, urban, and student health centres until special interest groups could be organized to discuss these facilities. Consequently, discussion of 7.2, 7.3, 7.4 and 7.6 was combined. Since the resources of each community differ, the group wished to emphasize that governments must continue to educate the general public upon matters of health, and health services, in order that a proper demand and use of facilities will occur. The programm in and around Manila, 'Which the group has o1,Jserved on several occasions, was cited as exemplary of the type which should be avatlable in every area. Rural centres generally provide a wider spectrum of opportunity for comprehensive teaching than is available in a single urban centre. Standards usually are set at a satisfactory level by the responsible government sponsor of health facilities; but, they can be elevated by the quality of teachers and students 'Who stimulate their colleagues outside the medical schools. Joint faculty appointments serve to give tbe schools some control and stimulus to improve standards. The critique offered by visiting students and faculty has served to elevate standards and contrib~ significantly to progress in several specific school areas. A very lively discussion ensued 'When some group members learned that the current relationships between the Ministry of Education and the Ministry of Health in certain areas make it extremely difficult for the universities, and their schools of medicine, to utilize the community health facilities. The group emphatically stated, in many ways" that every university ••

STUDY GROUP I

Page 2 that every university must be as functionally autonomous of political and financial control as is.necessary to pursue its high objectives with traditional academic ,freedom. There should be no question of political impediment to co-o~ration between these two groups. It was recoJDlllended that schools that are having difficulty securing outside facilities should establish _ not only student health services, but they also should draw the entire personnel of the university into a co~ operative health project whichthe medical school could operate as a model comprehensive health centre. Such a project would help to lessen the hostility and demonstrate the contribution which the Department of Social and Preventive Medicine and School could make to the national health welfare.

)

7.5

Since Dr. Smith's study paper has covered much of the topic, the group chose to discuss research rather broadly. I t was agreed that a fundamental difficulty in the conduct of research is the general inability of investigators to identify and define "thoughts, words, and things," to pose the correct question in the correct way. The groupdid not decide whether case work or survey methods were best for the field of social and preventive medicine. It seems that some problems of great magnitude must be approached 101 tially by mass survey techniques until enough knowledge has been acquired to enable the researcher to employ individual case methods. Every project does not require large numbers of samples; but all research requires careful biometric planning today. Social and preventive medicine still depends largely upon descriptive methodology to record social research. Publications of Fisher, Morris, Simmons and Wolffe were recoJJJlllended to the group. The members were polled to discover how they were teaching these princi, pies to medical students. A great variety of interesting responses was eliCited, demonstrating in general that the Departments were active in teaChing research methodology within their schools. In research, as in teaching, social and preventive medicine has much to offer other departments and the COJDlllunity. Notable among the potential contributions which have not been mentioned earlier are: (a) the personnel, facilities, time, and enthusiasm of a co-ordinated team seldom duplicated or available elsewhere in government for the study of clinical or operational research problems facing the national health authorities. the "integrated" and "comprehensive" approach to research which ignores traditional limitations of fields, leads research into all avenues, and borrows tested methods from every science.

(b)

WORLD HEALTH ORGANIZATION STUDY GRC'JP ON SOCIAL AND PREVENTIVE MEDICINE

REGIONAL OFFICE FOR THE WESTERN PACIFIC

25 October 1957 ORIGINAL: STUDY GROUP II SUMMARY OF OPINION

ENGLISH

(Topic

,..

.....

Practice Facilities and Community Research of the Department of Social and Preventive Medicine In considering the suggested items of the tentative agenda, the group decided that topic 7.5, concerned with research, was of such importance that it required recognition in the form of a separate agenda item. Accordingly, it has been designated as item 8. There were two reasons for this decision: (a) (b) The research function of departments of social and preventive medicine tend to be neglected and therefore deserve emphasis, and Consis~ywith

the earlier accepted division of functions of such departments into teaching, research, and service requires such recognition.

The thought was also expressed that the words "community research" in the title of agenda item 7 were too limiting since community research was only one aspect of the legitimate research interests of departments of social and preventive medicine.

7.1

Should the community and its services be used in medical education? There was unanimous agreement on this point without discussion.

7.2, 7.3, and 7.4 There are many different ways in which the resources of a community can be utilized as a teaching laboratory ~o train the physician. The use of health centres for such a purpose was unanimously agreed on. At such centres, however, a proper balance between service and training must be maintained - one must not be sacrificed for the other. Experiences at such centres can involve both observation and participation. Most in the group agreed that participation was a better learning exercise than observation. The group felt that a certain amount of "public-health sightseeing" is desirable for medical students. This would include visits to facilities such as water treatment plants, sewage treatment plants, slaughter houses, certain voluntary agencies such as schools for blind, etc. Local circumstances in individual countries will determine the amount and type of such an experience that would be desirable. It was •••

•

STUVY GROUP II Page 2 It was pointed out that the teaching hospital itself is a valuable community resource. Many teaching hospitals are assuming a new function in social and preventive medicine as a central health centre in relation to various peripheral health centres. Other ways of utilizing community resources in teaching students include clerkships at health facilities, area health surveys by students, and preceptorships with general practitioners.

7.5

See Group II's report on Topic 8. It was agreed that this topic had been adequately discussed under agenda item 5, and that further discussion woULd be repetitious.

7.6

WORLD HEALTH ORGANIZATION

REGIONAL uFFICE FOR THE WESTERN PACIFIC 25 October 1957 ORIGINAL: STUDY GROUP II SUMMARY OF OPINION (Topic 8) ENGLISH

IlTUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE

What are the fields of research appropriate to the Department of Social and Preventive Medicine? The need for a department of social and preventive medicine to er.gage in research activities was agreed on but many felt that the research function should not be over-stressed since the teaching function was so important. Most agreed that medical students do not ordinarily play a major role in the departments' research programme. The appropriate fields of research can be broadly divided into two categories - fundamental and applied. Much of the research work at present and in the past has been applied or directed research, and this trend will probably continue. Nevertheless, the legitimate interest of departments of social and preventive medicine in fundamental research is recognized. Reference was made to the working paper prepared by Dr. Smith (WPRO/SOC. PREV.MED./5) on research in social medicine. It was agreed that the classification of fields of research activity contained therein was generally useful. It was pointed out that the modern concept of epidemiology, concerned with multiple causation of disease and based on the triad of host, agent, and env:i.ronment, is the underlying theme of most research activity in social and preventive medicine •. There was heated discussion of the relative importance of these factors in multiple causation, and specific disease examples, i.e. tuberculoSis, were cited to support various views. Most of the group agreed that the most important factor at any given point in time is that foctor which is the most amenable to control measures •

WORLD HEALTH ORGANIZATION STUDY

mlaIOflAL OFFICE FOR THE WESTERN

PACIFIC

GROUP ON SOCIAL

AND PREVENTIVE MEDICINE ,

WPRojSOC.PREV.MED.jMinjl 18 October 1957 ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957

MINUTES OF THE PLENARY SESSION ON AGENDA 2 Institute of Hygiene Friday, 18 October 1957 at 10:25 a.m. CHAIRMAN:

Sir Charles Hercus CONTENTS

Opening • . • • • • • • • • • • • • •

Director-GeneralIs Message Discussion of Group Reports • Field Trip . .

.. ...... . ....

..•......•••.

WPRO/SOC.PREV.MED./Min/l Page 1 1

OPENING

Sir CHARLES HERCUS who opened the meeting stated that he was pleased to accept the invitation to act as Chairman. Before commencing the formal

business, he asked Dr. Grzegorzewski to deliver the message 'Which he understood the Director-General had sent to the study Group. 2 DIRECTOR-GENERAL'S MESSAGE

Dr. GRZEGORZEWSKI expressed regret that he had been unable to arrive in time for the opening. He stated that Dr. Candau had asked him to express to He

the Study Group his best wishes for a successful and fruitful discussion. particularly appreciated the contacts which would now be established by the

Organization with the medical training and research institutions in the Region. It vas in the medical schools and their various departments that the future of medicine was determined. The broadening outlook of students on the role

of the doctor in the community and the role of medicine in modern society in general was the basis of expectations for a still better, healthier and happier future for all people. From the beginning WHO had realized that

a n:,. long-term health progress in any country could onl.y be achieved if there were available a sufficient number of properly trained medical and related personnel. At the same time, advances in medical sciences and in social

community developments required certain adjustments in the preparation and orientation of the doctor. A very strong trend in medical and also nonMany national and

medical opinion could be Observed in this direction.

international world-wide conferences had studied the problems and searched for ways in which it could be solved. It was significant that in practically

all these discussions considerable emphasis had been put on the preventive aspect of medicine. programme. This matter was receiving due consideration in the WHO

The Expert Committee on Education and Training had analyzed the

problem in a broad perspective and made some general widely applicable recommendations.

...

WPRO/SOC.PREV .MED. /Min/l Page 2 recommendations. conferences. These had been followed by more detailed regional studies and

It was felt that gradually the impact of all these studies and

conferences and particularly the efforts of medical schools and their professors would result in a well-balanced medical educational programme where curative, preventive, social and psychological aspects would receive their proper share in harmony with each other. The Director-General hoped

that this Study Grcup would bring this goal closer in the Western Pacific Region as a result of the exchange of ideas and experience among participants. The opinions of the group would haoever be also valuable to colleagues in other regions. In closing, Dr. GRZEGORZEWSKI expressed the thanks of the

Director-General to the Government of the Republic of the Philippines for its hospitality and to the Institute of Hygiene and Dr. Lara under whose leadership the Institute had ac~uired

an international reputation.

The CHAIRMAN thanked Dr. Grzegorzewski on behalf of the Study Group for the very stimulating message from the Director-General and said that he was sure that he was speaking for the meeting when he stated that they appreciated very much the opportunity that WHO had given them to analyze the teaching in this important aspect of medicine. Without this statesman-

like action of WHO, they would not have had this opportunity.

DISClTSSION OF GROUP REPORTS The CHAIRMAN declared that the meeting would proceed to the discussion

of the group reports of the original groups.

Although each member had a copy

of the reports he felt that the reports should be read before the meeting. In the abso~oo

of the recorder of Group I, the CHAIRMAN read its report. then read Gro up II I S report and Dr. RAMOS Group III IS

Professor report.

w:: ~L'EIRO

The CHAIRMAN •••

WPRO/SOC.P.REV.MED./Mln/l Page 3 The CHAIRMAN announced that the meeting was now open for discussion. He stated that there did not appear to be very much difference of opinion in the three reports and there seemed to be geueral and substantial agreement that they were primarily concerned with education, that the objective is the training of the student so that he can act, do,and learn himself. He must

know how to use the literature, how to use the scientific method, he must be well grounded in the proper collection of facts, the proper approach to any problem which is new. The problem was primarily one of education as

shown in the reports, but there was also a vocational aspect obviously related to the country of origin and a judicious blend of the primary objective of education and the vocational must be obtained. It was his opinion that the

vocational aspect should be primarily dealt with in the post-graduate phase. The real interest was that of pedagogy, so that the students were instructed thoroughly in a sound method of approach. There seemed to be substantial

agreement on this fundamental principle that emphasis should be placed on helping the student to learn rather than teaching him. Medicine cannot be

taught, it must be learned by practice, by guidance and by maturity. H~

asked if any members of the plenary session would like to comment

or add further to the reports.

DR. GRZEGORZEWSKI stated that he would like to make two observations:

(1)

There did not appear to be mentioned in any of the reports something

which he hoped everyone felt was one of the objectives of teaching preventive and social medicine. By helping the student to learn this aspect of medicine

he would be given a chance to become a better doctor, he would be more complete and better in whatever kind of medical work he would do. It was

not just to make him better suited to the public-health or medical care plan or even for his individual benefit. It was however hoped he would become a better doctor •••

WPRO/SOC.PBEV.MED./Min/l Page 4 . better doctor if he realized the implications of social and preventive medicine. (2) Group I, in its reports stated that there was still a need for a

department of preventive medicine in medical schools, vith the ultimate objective of integrating its functions in clinical teaching. It was generally

thought that the objective of this department was to integrate the clinical aspect in preventive medicine or the preventive aspect of clinical medicine with the rest of clinical teaching. A belief was expressed some twelve years

ago that preventive medicine was a self-extinguishing discipline, that it existed because other departments of medical schools did not teach properly the preventive a~pect

of medicine. 'However, he understood that the present

views on the role of the department of social and preventive medicine in its teaching function were not limited exclusively to the preventive angles of clinical medicine and that it had a broader scope. As an example - the incul-

cation of the epidemiological method applicable to all branches of medicine. None of the specialized clinical or non-cUnical be to departments would The same refers

properl·y plaosd for the inculcation of this approach. other~ctors,

for instance the community approach.

The practice of com-

prehensive medical and health care, Which might have different meanings to different people, was the supplementation or utilization of all available resources in order to put them at the disposal of the patient. and progress of modern medicine had complicated this. The complexities

He felt that all these

things should be demonstrated to the students and that the departments of social and preventive medicine or whatever be always needed. name it would be called would

He asked whether the Grcupshould take the apologetic line

of approach that there was "at present still a need" for such a department but that in the foreseeable future there would no longer be a need for it. Another question was Whether the limitation ofperso~to

a department of

"preventive mediCine"

...

WPRO/SOC.PREV.MED./Mln/l Page 5 "preventive medicine" might not create a wrong impression in the minds of future readers of the Study Group report that social and other factors were omitted. The CHAIRMAN suggested that if preventive medicine were taken in its fullest application, even curative medicine was a self-extinguishing discipline. The group could agree that ideally as the environmental and other 'aspects were Unfortunately however,

, , _ y

, I

well under control, only the genetic factors were left.

it was a real world and even in the most advanced countries, there were mauy examples of disease that could have been with available res~urces,

prevented.

He believed that a hundred years from the present, preventive medicine would be a self-extinguishing discipline.

Dr. ALWYN SMITH said that both social and preventive medicine were being discussed and it would be very unfortunate if the group limited itself to preventive medicine as social medicine included the study of the needs of the community - both preventive and curative.

, ,

The CHAIRMAN felt that the group was getting unduly involved with words. He understood medicine as great medicine - SOCial, promotive, preventive, curative

and rehabilitative and it was not necessary to dissect it. be anything else but social.

Medicine could not

The job of doctors, in view of the excellent Taking'

development of para-medical disciplines, was to use these adequately.

an objective view, he felt that doctors had not completed their task until a particular individual was enjoying the best possible state of health, and SOCially, the individual was performing a satisfactory (to him) field of work. stopped short of thiS, they were not practising great medicine. There being no further comments, he closed die:::ussion on the matter and requested Dr. Ma to speak of the arrangements for the field trip • If doctors

Before doing thiS, Dr. MA announced that a Planning Committee had been formed the previous day composed of Sir Charles Hercus as chairman and Drs. Nobechi, •••

.. WPRO/SOC.PREV.MED./Min/l Page 6 ~

Nobechi, Lloyd-Davies, Monteiro, Ogata and Lara and the secretariat as The Planning Committee had been formed to respond to the wishes

members.

and needs of participants and to ensure that the Study Group would be a satisfying experience.

~: I

FIELD TRIP

The first field trip to the College of MediCine of the University of the Philippines, the Institute of Hygiene and the Philippine General Hospital would take place at 1:30 p.m. Time would be provided to enable participants

to raise questions and discuss what they had seen. The meeting adjourned at 11:15 a.m.

WORLD HEALTH ORGANl2.ATION STUDY GROUP ON SOC TAL AND mEVENTIVE MEDICINE

REGIONAL OFFICE FOR THE WESTERN PACIFIC

WPRojSOC,PREV,MED.jMinj2

21 October 1957 ORIGINAL: ENGLISH

Manila, Philippines 16-29 October 1957

MINUTES OF THE PLENARY SESSION ON AGENDA. ;5

Saturday,

Institute of HYgiene 19 October 1957 at 2:15 p.m. Sir Charles Hercus CONTENTS Page

CHAIRMAN:

1 2

Group Reports

..•

• ,

., .

Evaluation of Past Sessions Field Visit ,

.......

.• , . .... ., . ...

i "

'1.

WPRO/Soc.P.REV.MED./Min/2 Page 1

GROUP REPORTS The meeting opened with the reading of the gm up reports on item 3 of the agenda. The CHAmMAN read Group I's report on behalf of its recorder who was Professor THIEU read Group II's report.

not present.

Dr. A. SMITH stated

that item 3.10 of Group II's report referred to "Research" which topic the group had discussed as part of Agenda 3. The CHAIRMAN then declared the meeting open for discussion from the floor. He asked if there were contrary views which the meeting would like to hear discussed.

Dr. A.SMITH asked that the recordelBinclude in their group reports any disagreement which occurred during the discussions. He stated that it was

rather difficult to write a lively report when the disagreements were ironed out and presented in the form of a compromise. assigned, it was easy to fill in the blanks. Professor LLOYD DAVIES referred to the list of subjects which should be included in the curriculum. subjects for pre~ntive

In the group to which he was

This was described as a' traditional list of

and social medicine but he commented that in fact most He cited genetics as an example of a

•

of the subjects were fringe subjects.

subject no more belonging to the problem of social and preventive medicine than to any other department, or nutrition which belonged even more to biochemistry, or biostatistics which was not a social and preventive medicine problem but because the department had on its staff a statistician for other purposes, biostatistics was taught in the Department of Social and Preventive Medicine. His concern was not that the Study Group should not

deal with the branches of social and preventive medicine but that it should 1

endeavour to identify the essential theme of social and preventive medicine. It seemed to him that unless this was done, the Department did not stand up to having its place in a medical school. He reiterated that the meeting endeavour to •••

WPRojsoc,fREV_MED.jMinja Fage2

endeavour to identify the essential theme of the Department, in relation to the patient's home and environment I

particularly

BJ environment, he meant

physical, social and all other forms of environment of the human being.

Dr, A. SMITH commented that perhaps one of the reasons for including fringe subjects Was because of the duh1 ro1e of social and preventive medicine and the Study Group was discussing social and preventive medicine: Professor MONTEIRO asked what consideration the Study Group could give to the already crowded syllabus of medical subjects and the long list of subjects enumerated as being essential to the curriculum of social and ventive medicine. pre~

He said that the Group agreed that these subjects were

essential and at the same time it felt that the syllabus was already overcrowded. Dr. GRZEGORZEWSKI, replying to the problem posed by Professor Monteiro,

said that in one of the group reports read at the Plenary Session for Agenda 2, the objective of medical education had been discussed. and he presumed, accepted in the form given by the Association of American Medical Colleges. A few

paragraphs on the statement of the objective referred exactly to the problem before the meeting and stated even specifically that teaching in detail of several subjects should be avoided. This attitude may be and should be

interpreted as an indication that some of the actual curriculum or curriculum still taught in some medical schools, might be usefully revised and thus the newer contribution to medical curriculum may find its place. Progress in medicine has contributed to the overcrowding of the curriculum. Bacteriology came at the end of the century and was added to the Biochemistry had developed very strongly

curriculum; radiology too was added. and it too was added.

Therefore there was now a need, and in some schools Tbis had become

it has been done already, to revise the accumulated material.

urgent not •••

•

WPRO/SOC.PREV.MED./Min/2 ~e 3 urgent not oniy ror social and preventive: medicine but all branches or medicine. To the curriculum should be added such subjects as radiation,medicine which is something more than radiology, but how much or it should be put in the general undergraduate curriculum was another matter. The fact was that it was not

just a question of adding to the curriculum but that there was also the need to know what to subtract. The definition in the statement or the Association It

of American Medical Colleges provided a suitable approach to this problem. was not in the individual department but in the whole raculty council that a decision should be taken notwithstanding the possessive attitudes or some colleagues with regard to the subject that it had been decided to reduce.

That

was the only way which could be taken. RequiremeQts on the students' time should be modest but this could only be obtained at the expense or some older material which had become obsolete. The CHAIRMAN said that the problem concerned every dean and every medical school. At the University of otago Medical School, there was a curriculum He stated

committee which was constantly reviewing the whole or the curriculum.

that it was very difficult to get departments to take a large mass or their material out. It was just like extracting teeth and just as painful. The

whole point was that the curriculum was only a matrix into which was built the content. Mental anaesthesia could be produced in a student ir he was battered It was in general principle the spirit rather than However,

with facts arter racts. the substance.

It was easy to say but difricult to secure.

speaking broadiy every medical school was trying to reduce its actual load. He mentioned the Goodenough Report in Britain which recommended that if schools did not cut down their matter their grants would be reduced. He did not remember

such a threatening statement ever being issued by any ofricial body in its reports on medical

WPRO/SOC.PREV.MED./Min/2 Page 4 on medical education in Britain. He added that the number of reports issued in

Britain was quite outstanding but that the action that followed was rather disappointing. He said that it was agreed that as far as possible the factual

load must be reduced, that a student should be given time to think, to use the library - in other words to become an educated person able to learn for himself. If a barrier was continuously put to that end, the student would end up exhausted and bewildered. The CHAIRMAN said that if there was no further discussion, Dr. Ma would make some announcements.

. t:J reme(~y

EVALUATION OF PAST SESSIONS Dr. MA said that after receipt of the evaluation of the past sessions on

Agenda 2 and Agenda 3, G00e of the

attetlp1; has b.cen rl::cle i:lvlvec.

difficult:i.cc

T~erE

were

however problems related to the groups themselves.

He said that one of the

comments with regard to group participation was that often the members would stray from the points under consideration or stray from the topic of the agenda., Although it was not advocated that the meeting follow strictly the topics sug~estedJ

wherever possible it was advised that consideration of comments It was thought that this

be given with respect to the topic under consideration. was something the groups could work out themselves.

Dr. MA requested that the

•

evaluation sheets for the meeting that had just terminated and for the present plenary session be filled out.

FIELD

VISIT

Dr. MA announced that the field visit scheduled on Monday, 21 October, would start at 7:30 a.m. Transportation would be provided by the Regional

Office and would await the participants at the Luneta Hotel. He reminded

•

WPRO/SOC.PREV.MED./M1n/2 Page 5 He reminded the group of the arrangements for the excursion to Tagaytay the folioving day. Transportation was being prtlvided by the Department of' Health Dr. V. RAMOS also kindly off'ered the

through the arrangement of Dr. T. Gomez. use of his car for the trip.

Dr. LARA offered to make arrangements for anyone who would be interested

•

in playing golf. Dr. MA invited participants who were free from 4:00 to 6:00 p.m. on

Sunday to the

Arrrry

sud Navy Club.

The meeting adjourned at 2:50 p.m.

WCRID HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE HEDICI;NE

REGIONAL OFFicE FOR . THE )i;STERN PACIFIC WPRO/Scx:: .PREV oMEDo/Min/3 24 Ootober 1957 ORIGINAL: ENGLISH

NardIn, Philippines 16-29 October 1957

Mll-rUTES OF THE

PIENARY SESSION ON ACENDA. 4

Institute of HYgiene Tuesday, 22 October 1957 at 10:25 p.m. "

Chairman: Professor T. A. Lloyd Davies

CONTENTS

Discussion of Group Reports AnnoW1Cements

WPRo/soc.PRilV .MED./M1nIj Page 1

The CIL\.IRNAN called the meeting to order and asked ;I.f there were any comments on th~ rninut~s

of the plenary session for agenda 3.

There being

none, he called on Dr. MlTTHEWS to road Group lis report; wh:1.ch had been prepared by Sir Charles Hercus as Dr. Matthews had been sick. report was read by Dr. EDNONDS. DISCUSSION OF GflOuP REPORTS The group reports having bem read, the CIL'l.IRMA.N declared the matter open for discussion. Dr. MA. stated that before the meeting proceeded to the discussion the reports, he would like to clear some points of terminology. . to the term "underdeveloped countries" used in Group I' s report. Group II's

He referred He queried

whether it would be more appropriate to sC13 IIless-developedll .countries. The CHl.IRMAN stated that the point was the sense in which the word was used. It was true that the word had an emotional connotation but he

felt that in so fnr as the term was used in the report it would mean those countries in which services were only being introduced. It was only natural

in a representative group that some countries would have developed different

forms of services tron others.

Sir CILiRIES HERCUS said that the term had boen used ns stated by the Chairrnrul, pointing out that the question being discussed at that time by the group was the development of the different teaching functions in the undergradUE. te schools. The CHAIRMAN said that it was then agreed to take the word in that form. He asked it there were al\Y other point of terminology in both of the reports read which required discussion. Dr. MA. raised •••

°WPRO/SOC.PREV.MED./Min/3 Page 2

Dr. MA raised another point in tho last paragraph of Group IIts report, under item 4.6(a). He presurood that the words "Social Medicine Departmentif'

actually stood for Social ani Preventive Ecdicine DeIBrtment.' Dr.- ErMONDS confinned that this was so. , The CHi.IRMAN made a suggestion tha t the recorders might perhaps use the abbreviated form of "SPM" for social and preventive medicine. Referring also to Group IIi s report, paragraph 4.6(b), Dr. UCHTENWAINER remarked that the paragraph sounded to him as though anyone who would

qualify in such subjects as for example ana tol1\Y could qualify in the teaching of preventive medicine. He did not however think it necessary to add social

and preventive medicine after each of the qualifications listed. The CHAmMAN commented that social and preventive madicine was a new subject and it was not easy to find people who had had direct experience within the subject. It was therefore often neCElssary to appoint people He mentioned a medical

whose major experieree has been in other fields.

school in Ireland where the social medicine professor was formarly a professor in physiology and that that had been considered a sensible appointment, He adJed however that the definition of social medicine did

var,r from people to people and from school to school. DR EDMONDS said that section (3) of item 4 .. 6(b) was rather broad but that the keyword was in "appropriate post-graduate degrees".He said that

Group II had not been particularly specific about which types of post--graduate degrees were indicated. Dr. EDMONDS thought that tho term could be changed It had

to "post-graduate qualifications ll or "post-graduate experience".

been Sl18gested by one member of the group that the ooad of the department should have a ••••

•

WPRO/Soc.FREV~./M1nI3 Page 3

should have a soum aoademic record am should have acquired such postgraduate degrees or formal qULlificntions expected for his age at the time of appointment. Dr. SMITH stated that when ha suggested tho importance of a soum.

academic background he had in mind an academic record which would command the respect of the facul1¥ and students of the Universi1¥ concerned. When

he suggested academic distinction in consideration of age he was beartng in mind the degrees in English schOOls not attainable by young men.

was not easy to find, for example, young doctors who were members of the Royal College of Physicians. Dr. EDl'lONIlS wondered if the meeti~

could discuss whether or not

formal training in public health was necessary for 1he head of the department of social and preventive roodicine. Dr. SMITH observed that all the prof easors under whom he had studied did not have these q1.W.lifications .:md too lack did not apparently lessen -~

their efficiency. Dr. GRZEGORZEWSKI remi.nrl.c:d the group the. t when curric ulum content was discussed, there was agreement that conduct of teaching would dep:md to a

•

considerable extent on the type of problems which the students would meet and should be acquainted with. had changed substantially. The preventive and social aspects of medicine

The era of bacteriology and pathology had given ctk~ges

way to nutrition am radiation and further

were forthcoming.

thought that some kind of agre(31lent on the real problems to be faced by the students should ~

reached.

In the type of situation where the main interest of social and ••••

WPRO/SOC .PREV .MED/Min/3

Page 4

of social and preventive medicine would be directed to those subjects which clearly belonged to the realm of public health, a person familiar with these aspects would be preferable. There were countries where social and preventive

medicine mare or less concerned itself with problems of individual health and certain countries linked social and preventive medicine close~

with )

clinical medicine so that public-health qualifications were less essential. If a chair in a discipline or branch of medicine was interested in preventive aspects and in looking at medical problems in groups or masses this could be achieved without a classical diploma in public health. In the western

Pacific, more countries were in the stage of development of public-health activities and at the stage where many health problems should and could be tackled only from the public-health approach. He suggested that perhaps it

would be more suitable to indicate that the head or senior member of the department required less public-health q~~lifications

in a community which

had solved public health and which needed to ground students in the clinical delicacies of prevention. The CHAJJl.HAN stated that the group was discussing under-graduate training ~d

not post-graduate training or the organization and functions of It was true that public h&llth and

a national publio--health service.

preventive medicine grew out of bacteriology and the world had passed on to the stage of radiation and other hazards. Ho~ever,

there always had been

and would be the element of human relationships.

He suggested that as far

as the teaching of undergraduate students was concerned, it was preferable to have somebody who was most closely associated with human relationships which particularly ••• <:

WPRo/soc .PREV .MEn ./Min/3 Page 5

which particularly concerned the student, the doctor-patient relationship, which to his mind meant that the head of the department should have been a physician in the English sense or a general practitioner and in close contact not only with the physical environment but also the social and interpersonal environment of medicine. His assistants should have training in

public health or other branches of social and preventive medicine. Dr.

'11&~~agreed

that at least some of the staff should be trained

in general practice in order to know the problems and viewpoint of the general practitioner and to be aware of the general problems of health both of the individual and the family. While the professor should be a consultant, When a consulting

his training should not be that of a consulting physician.

physician with specialized training, as in internal medicine, teaches social and preventive medicine, it was often the complaint that the doctors turned out usual~

regarded patients as cases of interesting diseases This was mainly due to the fact that they were trained

rather than people.

by a consulting physician who had no contact with people in the human sense. If doctors were trained by general prqctitioners, they would be trained in human relationships. At the present time, the consulting physicians had They however still

almost discovered the importance of home environment. use the social worker in this respect. Dr. LICHTENW1~INER

wondered i f it was essential for the professor in

social and preventive medicine to be highly trained in the clinical school. This seemed to be asking for a specialist in social ~nd

preventive medicine

with additional specialties in clinical medicine, internal medicine, etc. He asked whether •••

WPRO!SOC.PREV.MED./Nin/3 Fage 6

He asked whether this resulted from the fact that in order to get acceptance by the clinical and other depL,rtments it was necessary for the professor of social and prevontive rredicine to exhibit the sarre skills as the other professors had or whether it was a defense reaction of those who had specialties in social and preventive medicine but in acquiring these specialties had left behind the other clinical skills. Dr. THlEU thought that the definition of qualif:is::ations of a professor in social and preventive medicine was important to his country. The majority

of doctors there had been traimd in Western traditions and he hoped the meeting could solve tho problem along the lines of Dr. Edmoooa r suggestions to enable the practising doctors z.nd medical students to discover the reeds and envirorunent of the people. Dr. GRZEGORZEWSKI ."..greed vlith Dr. Thieu but reminded him that the Stucl,y Group had been organized for D.n interchcnGe ani analysis of opinion and problems with areas of agreement and disagreement. He submitted that it t

was not realistic to expect any one person to possess all the skills and qualifications mentioned and did not think it proper at the present stage of development of social and preventive medicine to fix formal requirements of this nature. In most countrios, one could define qualifications for a

professor in histology or ch er.d.s try , but social and preventive medicine was at a stage where the professor should preferably have initiative and talent rather than formal degrees in public health. It was better to have

a proper leader who did not have any formal status in public health but had such qualifications. iI. good clinician or one who h.:"1.d a diploma in

public health but •••

WPRO/soc .PREV .MED ./1.&/3 Page 7

public health but who was not sui kb1e fer the post might be appointed and thus block the development of one generation of doctors. Dr. GRZEGORZEWSKI suggested that the bodies who set up such qualifications should consider knowledge 'of !Jroblens and people am that they se1eot a person from the point of view of total clear prescription. Dr. MONTEIRO said that the problem was faced by the Facul~ persona1i~

and not on one or another

of the

Universi ty of Malaya when the chair for socie.1 and preventive medicine was vacant. A. committee considered the requ:ir emants for the filling of tre post

and it was decided that the incumbent should be an educated physician in the English sense of the w orrj in the event one with cons iderab1e experience in indus trial health was available. Dr. LIDYD ThWIES pointed out another involvement in tennino10gy. When it was mentioned that a qualification for the post of head of department

should be a consu1tant l it was not meant to include consultants in other

particular branches but specifically consultants in socfu1 medicine only .. Dr. KII1lORN referred to the statement in the report of stuqy Group II that the absolute minimum for a department of social and preventive medicine He recounted the experience

should be a fu11-tima head of the depnrtment.

in Hongkong about ei@1t years ago when a full-time head of the department was appointed but had to resign after two years as he felt that he could not carry the wcrk alone. He believed that thl.lre should at least be a rnini.mum

of two full-time members of this department. Dr. MONTEIRO stated ••

• WPRO/SOC.PREV~./Min/3 Page 8

Dr. MONTEIRO stated that the

implicatio~

was for a full-time departlilmt

head, to form the nucleus of a dep artment. Dr. SMITH suggested and Dr. KILBORN agreed with the example of the Universi 4v of Bristol where there was one part-time head of the dep artment and two full-tiroo assistants. Dr. I.J.OYD Di,VIES thought that this was common practice in countries short of money and shortages of staff in ministries sorootimes precluded additional staff in faculties of medic ire • The field of social and preventive

medicine was so vast that i t would be quite impossilile not to have two or more staff members if the departmant was to be an effective one. It was

agreed that at least two full-time members would be in the department i f it was to function properly and progress. Dr. THUAT referred to item 4.2 of the report of Group II on item 4

of the agenda and suggested that the department of rocial and preventive medicine should co-operate with other depar tments. independent and individual. It should not be too

He personall,y thought that it should be within

the school of medicine in order to co-operate adequately from the lecturing point of view, conferences, seminars, clinical examinations and research.

If there was to be a certain degree of independence, it should be stressed that this was only a budgetar,y one since it was necessary to have an independent budget owing to the magni-rude of the work involved in social and preventive rnedicine. given under epidemiology. He also requested information on the example

Dr. GRZEGORZEWSKI ••••

IIiIII . ,

•

WPRO/SOO .PREV .MED ./Min/3 Page 9

Dr. GRZEGORZEWSKI thought that there was SOllE misunderstanding as far as terminology was concerned. With regard to independence of the department, giv~

there were tendencies in some universities to

the professorship in

social am preventive medicine to SOllE other existing cha:ir, such as internal medicine, and the implication was that the head, or the department, should be an independent one wi thin the universi 1:if • outside the universi 1:if was never intended unacceptable situation. Ii. completely independent body

as this would create an

It was simply desired to have the chair of social

and preventive medicine on the same footing as other chairs in the faculty of medicine.

Tha t the depnr tment should have a se~Qte budget was ~nother

matter entirely.

Regarding epidemiology, there was a difference in French The report referred to modern ep idemiology, which

and English terminology.

covers llEthods of study of various health problems, or the conditions that influenced health, and not merely the question of communicable diseases and epidemics. It had been agreed that there should be no exclusivi4Y in the

department of social and preventive medicine on matters of epidemiology. Dr. LIDYD DAVIES pointed out that the last paragraph of Group Its report covered status. the difficulties of recruitment of staff of adequate

The meeting had been maintained at a realistic level by considering

the important factor of salary in attracting adeqw tely qualified staff who would command the respect of the students and their colleagues. i

.. 2. ANNOUNCEMEN'IS a. The Group was reminded that agenda 6 would be d iscusse~ in plenary session that afternoon. b. The Regional

· , .... WffiO/SOC .PREV .MEn ./Min/3 Page 10

b. The Regional Office was prepared to pay participants any surplus per diem allowance up to 2Cf/, of the total c. ArrD.neements were being ~de

their home currency.

for the mailinc; of documents gathered Participants would be

during the Study Group meeting by surface mail. advised later of procedures regardinc; this.

d. The Group was requested to revievlthe vnrious suggestions made with respect to the organization of special interest groups. It was necessary

for the secretariat to know the size of each group in order to plan accordinc;ly. The meeting adjourned at 11:45 a.m.

, j

WORLD HEAIIrH ORGANIZATION STUDY GROUP ON SOCIAJ AND PREVENTIVE MEDICINE ~n1J.a,

REX} IONAL

OFFICE FOR

THE WESTERN PACIFIC

WPRO/SOC.P.REV.MED./Min/4 24 October 1957 ORIGINAL:

16-29 October 1957

Ihil1ppines ENGLISH

MINUTES OF THE PIENARY SESSION ON AGENDA. 6 Institute of Hygiene Tuesday, 22 October 1957 at 2:00 p.m. CHAmMAN: Dr. E. Grzegorzewski

CONTENTS

Role of the Department of Social and Preventive Comprehensive Health Care

~d1cine

WPRO/SOC.PREV.MED./Mln/4 Page 1 1 ROLE OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE HEALTH CARE

m COMPREHENSIVE

Dr. GRZEnORZEWSKI pointed out that this session was a little different

from the others because there was not as yet a clear concept as how to run it. The groups had. discussed the presentation briefly and the Planning Originally

Committee had also considered how this item should be tackled. ).

the proposal was a panel of a ff!!W members with firsthand experience in comprehensive medical ?r health care who would give an account of their experience out of which some conclusions might be drawn. In the course of the prepa.ra.tory

exploration it had become evident that there were not enough persons who felt their experience was sufficient. In order however that this item should not

be completely dropped, a kind of unpretentious way of presentation had been chosen, which would consist of some introductory remarks on the subject by himself follOWing which Dr. Ka.tsunuma would describe a type of project which seemed to be closest to the matter under discussion. would then follow. Dr. GRZmORZEWSKI stated that the title of the item of the agenda was:

Discussion of the project

·"Role of the Department of Social and Preventive Medicine in Comprehensive Health Care." In some preliminary discussions it appeared that the term

"comprehensivelEalth care" was not particularly clear to all and he suggested that rather than attempting to adopt one or the other definition, as for instance that given in one of the working papers, some exchange of views on the substance of the term might be preferable. He then referred to the first SUb-item of the agenda: "6.1 What

is the concept of comprehensive health care", and asked for a dynamic approach to this concept. Consideration had to be given to the process of evolution

and therefore in any straight definition, some of the problems would be relieved just •••

WPRO/SOC.PREV.MED./Min/4 Page 2 relieved just after it had been adopted because some other events or opinions might throw a different light on it. angles. The matter might be approached from two

First, from the point of view of organization, comprehensive health

care would comprise only services useful for the accomplishment of the task envisaged - health care programme. As discussed that morning it was not wise

to say which parts belonged to them and which did not, because the word "comprehensive" meant all inclusive. Comprehensive health care might be said,

for instance, to include all services which are essential and which contribute to the health and welfare of the human being. It must, however, be understood

that sometimes the boundaries were very flexible and looked differently in different eyes. If the matter were turned around and looked at from the point

of view of the individual or the baSic social unit it became the family, and a more precise picture appeared of what might be understood as comprehensive health care. This would include all services useful to the family and which

met the needs of the family in the sense of prevention, cure and rehabilitation with the adjacent social services. Again here the questions arose - '\fuat The simplest form was

is the need?" and ''Who has to establish those needs?"

the demand, but there was no doubt that the demand did not necessarily respond to the real need. Some examples had already been given of comprehensive

health care of various types,for instance if special groups of population were taken, for instance the army. Here was found the closest possible

example of comprehensive health care covering preventive, curative, rehabilitative, psychosomatic and in a way social aspects of health. In some countries the

army personnel, together with their families, were subjected to this sort of care which might well be called comprehensive. There was also topographical

limited comprehensiveness where the population of certain districts, usually a demonstration district, received all types of care considered essential in the •••

WPRO/SOC,PREV.MED./Min/4 Page ) in the light of present knowledge and social circumstances. There might even be

larger topographical or geographical units and there were some countries which, at least in principle, had decided to make all types of services in the field of health available to the whole population. It was significant enough in

those countries, e.g. in Great Britain and USSR, that the word comprehensive was not used in their national health service. It was w~thin

the national health

service and its advisory body that the building up and expansion of the services took place ideally and practically, and sometimes reached the limit of what was elsewhere called comprehensiveness. Dr. GRZEGORZEWSKI stated that there was another approach to this compre-

hensive care, which he had already mentioned but wished to repeat again, i.e. the establishment of the real needs which could be covered through the prevention, care, rehabilitation and promotion of health with regard to the individual, the family and their physical and social environment. This provided all the

possible objectives which could be thought of in this connection. Another point in the agenda was: "6.2 What is the responsibility of the

medical school in teaching comprehensive health care with special reference to that of the Department of Social and Preventive Medicine?" Dr. GRZEGORZEWSKI felt that the concepts of medicine, any kind of medicine,

usually developed

in medical teaching institutions not by the charter necessarily The current concept of medicine should

but merely by the factual developments.

also be and usually was expressed in the type of teaching which is given. There was nothing particularly new in this approach if it was stated that medical schools should give that kind of teaching which was most in agreement with the most advanced and progressive trends in contemporary medicine. Dr. GRZEGORZEWSKI stated that he wished to introduce an element which was not

a new element but rather a registration of fact, namely that if the development of medical •••

WPRO/SOC.PREV.MED./Min/4 Page 4 of medical and health care were studied it could be said that a few centuries ago, maybe not even a century ago, one family doctor practically satisfied all of the recognized needs for health care in the family. However with the progress

of medical science, it had become impossible to maintain all those services in the hands of one person no matter how competent he might be, and a number of other persons, institutions and services had grown up. Because of drug supply, of

medical analyses, of physi0therapy, vaccination, etc. there was invoked a larger and larger group of specialists, services and institutions. From the point of

view of the interested person, who was also the main object of interest - the patient, his person and his family - it was evident that it was difficult to expect that person and his family to realize the scope of modern medicine and all the different elements which composed it. It was therefore the responsibility

of the physician and whatever health and medical organization existed, not necessarily state, either voluntary or organized by the medical profession of the community, to convey to the person and his family theinformation about the best possible utilization of all those resources. Dr. GRZroORZEWSKI quoted

the experiences of the Harvard Medical School whose students were asked to investigate problems about the patients who had been informed of the availability of various sources of health care. They had been extremely depressed by the

discovery that the persons and their families who were investigated were unaware of the resources and possibilities of utilizing them. This was a

practical aspect of immediate concern to the training problem that the doctor should realize the diversity of the means by which those needs could be met. A practical aspect of training was that assistance should be given to the young colleagues to enable them to appreciate the complexities of the needs of a person and his family under !jis .c.rE: and also the availability of the various resources which Ln one way or another could meet those needs. Item 6.3 .•• )

WPRO/SOC.PREV.MED./Mln/4 Page 5 Item 6.3 of the agenda: health care?" Dr. GRZIDORZEWSKI

''What are the methods of teaching comprehensive

stated that this method had been specifically developed t~aching

in many places although the fact that a good physician

in some older

medical schools provided this kind of information and orientation without having instituted any special programme should not be overlooked. In the older times

part of the training was done by apprenticeship when young doctors or students went with a practising doctor during his rounds of patients. Now with all the

complexities of social and scientific progress, should the most primitive or very agreeable method still be used or should more organized ways or better suited methods for application in these circumstances be established. In some

places; for example at the Medical School of the University of Puerto Rico, a special method had been established, a programme called comprehensive clinic. In this arrangement the senior medical students were assigned offices on the hospital premises where they took care of outpatients and their families, or patients coming to the hospital, tried to establish the needs of the patients and, with the help of social and public-health workers, of their families in a given district so as to try to implement the basic duties of studying the need and providing all the necessary facilities available in the community to meet those needs. The University and the students were very satisfied with the There were of course a number of other ways, ranging

particular arrangement.

from the non-existence of any specific programme but simply ralying on the good understanding of the problem by all the teaching personnel, i.e. interns, residents and whatever were their parallel names in other systems of organized practical teaching of medicine. Although there was a variety of existing needs, some kind of idea of the scope of medical and health problems should be inculcated in the minds of the students during •••

WPRO/SOC.PREV.MED./Min/4 Page 6 students during their preparatory years so that when they actually met people in their clinical learning they would appreciate that their needs might be very varied and worthy of study because this was the only way those needs could be reasonably ~~proached

within the existing pattern of social organization.

Very often in the formulation of needs and possibilities in the field of health, activities moved a little in the tail of progress. to adjust medical and health services to reasonable and a right approach. conditions This was an attempt was quite

~ich

Consideration should, however, be given to and the question asked

the desirability for a little more active attitude, ~at

social and administrative arrangement should be desirable in the interest In this way social and other developments could be It was

of health and human welfare.

influenced to a certain extent and conditions not taken for granted. necessary to act both by self-adjusting and also by influencing these

conditions as one of the forces in shaping the future of communities and countries. Dr. GRZEGORZEWSKI felt that a certain orientation along these lines

should be given to medical stUdents. Dr. GRZEGORZEWSKI then stated that Dr. Katsunuma would now inform the

group of a practical project he had tried to develop. Dr. KATSUNUMA referred to the programme started two years ago in one

of the two teaching hospitals attached to the Medical School of the UniverSity of Tokyo. The branch hoepital had been selected as it had only 200 beds and Dr.

it seemed easier to try out new procedures in a small-scale hospital.

KATSUNUMA outlined the way in which the hospital was organized as shown on the mim eo graphed sheet distributed to participants (see Annex I). Clinical medicine

covered all the medical field as far as the clinical aspects were concerned, there was also a centralized department, a central laboratory, pharmaceutical unit and an admin~rative

• )

unit.

The department of health guidance had been establishea as •••

WPRO/SOC.~.MED./M1n/4

Page 7 established as a centralized bo'dy and under it came various units such as the mental health unit, the well-baby unit and geriatric'j1hit, which were already established when the programme was started, although the geriatric unit had been attached to the department of internal medicine, the well-baby clinic to paediatrics, and mental health clinic to psychiatry and neurology. When

the department of health guidance was set up, the above units were moved under it and a health counselling unit, eugenic counselling unit, industrial health unit, home extension unit and also medical-social work unit added. The

personnel who worked in this department was jointly appointed to departments concerned with social and preventive medicine and clinical medicine and vice versa. At the moment the personnel consisted of the following: public-health

nurses, physicians, medical-social workers and a clinical psychologist. Dr. KATSUNUMA stated that a.s far as the activites of the department

were concerned he would like to mention in particular the work of the special units - the mass physical examination unit and social survey unit - which worked for the department when necessary. The mass physical examination unit

had often been asked to do some screening and examination in homes or schools or sometimes in the rural community mainly as a case-finding activity. social survey unit had in the community: o~

The

three occasions been asked to undertake a survey

two in rural communities and one in an industrial one.

These units were run by the head of the department and through him directed by the head of the hospital. There had been satisfactory co-ordination

between hospital and administrative agency resarding the health of the community where the hospital was located.. The size of popuJ..s.tion of the community where the hospital was located was about 150 000 and there was one health centre. The number, of medical practitioners was nearly four per lOOO population. The

activities of the department of health guidance had been carried out by means of case •••

WPRO/SOC.PREV.MED./Min/4 Page 8 of case-work method, group-work method and community approach. Actually the case-

work method had been used for patients coming from outpatient clinics or patients admitted, and the group work for home extension of health and medical care; for the community orgoanization mass screening and the social survey units had been used as well as the channels of health centres in the community in the form of evaluation. Excellent relationship existed with the health units.

Dr. NOBECHI stated that he had been requested to give additional comments and observations after Dr. Kataunuma's talk but that he preferred to give some information on his experience in allied work. Japan was divided into 750 health centre some extent comprehensive health care. districts and had therefore to

The area covered by each health centre was,

however, too large and some attempt had to be made to have comprehensive health work in a topographically limited area.

Dr. NOBECHI stated that he had been

requested by the nursing department to take leadership in a type of comprehensive health care which was titled nationalization of public-health nursing activities.

" II

Dr. Katsunuma had also advised in this project.

In a district of 2000 population, a public-health nurse was assigned in addition to the health centre staff. The first thing done was to make a survey of the social conditions in this area. A group of eight students from t

the Faculty of Social Science in Tokyo University had been invited to participate. A random sampling had been carried out following which the nurses visited each house in the area to collect information on health conditions. They found

nearly 60i suffering from chronic cancer, lung tuberculosis, nephritis, etc. without getting any medical treatment and the first steps was to take care of these patients under the livelihood protection law of Japan. At the same

time the physicians in this area were asked to refer the names of the patients to the health centres. Work had •••

WPRO/SOC.PREV.MED./Min/4 Page 9

Work had also been done in the rural areas.

Recently the Government had

instructed all communities to amalgamate themselves into bigger communities. One such area formed by the amalgamation of four communities had been selected and a social survey . carried out. Information was collected on the economic

conditions of the members of the community as well as their degree of health knowledge. All patients were thus taken care of, especially the clinical cases

in bed at home who had not known of the livelihood protection law and other social security laws so that the comprehensive health care could be increased. Dr. KUSAMA stated that the labour laws of Japan provided for welfare and

health services in factories that employed forty to fifty workers or more. There existed a Boo-bed hospital with a welfare section that took care of the preventive side of medicine. hygienist. care. This section had a very well-trained industrial

It was not called comprehensive health care but industrial health

Dr. KUSAMA was of the opinion that comprehensive health care did not pic~ure.

convey a clear side.

Industrial health care had a therapeutic and preventive

The preventive side was manned by well-trained doctors. with threeor four This included not only

trained nurses in addition to other health workers. physical examination but eye~

ear, nose and throat specialists, dentistry, Any cases found were taken over to the hospital

surgery and internal medicine.

where they were given skin tests and if found positive inoculated with BOG. Three months later the tests were repeated. The welfare section had police

powers in their inspection of illumination, ventilation, aCCident, prevention, etc. This section also carried out laboratory work on matters such as elements causing undue fatigue. Dr. KUSAMA stated that eleven years ago he knew of

a factory with 24/100 TB cases.

How as a result of the concentrated campaign It was very difficult

of this section the incidence of TB was less than 0.4%.

to evaluate •••

WPRO/SOC.PREV.MED./Min/4 Page 10 to evaluate the results of preventive medicine but in this case the factory had been saved the expense of keeping workers in TB sanitaria. Students

were sent to such factories where they were trained in this side of medicine. Families were included in the programme and the hospital had an obstetric, paediatric and gynaecological. ward. When a labourer lost his job he was

insured and received for six months about

60%

of his salary.

Health care for

himself and his family continued for one year. Professor LLOYD DAVIES thought that the most important contribution made was the concept put forward by Dr. Grzegorzewski. One of the difficulties

in comprehensive health care was when national health services were introduced. First, it was not in itself a means for increasing the level of health of the population. Personally he felt it would give rise to the standard of living.

The other point was that the amount of reported sickness for which help was demanded went up with the introduction of a health scheme and it was this factor which nearly broke the scheme in England. The essence of comprehensive

health care was in his opinion some scheme in which both treatment of sickness and also the control of environment were covered and he cited as examples, the army, industrial and employers' schemes ¥here students could derive much ·benefit. The ILO had recently published a report "Work in the Plantations"

where the question of whether or not the residual requirements of old comprehensive health care were not now holding up the development of comprehensive health programme in UDderJeveloped countries had been raised. In

Malaya, the Government had as in the past unloaded the burden on the employers and this had become a hindrance to health schemes.

Dr. ICASIANO stated that the term comprehensive health care was not a very well-known term in the Philippines but the public-health service was geared on what might be called medical health care. Manila, a •••

J I

WPRO/SOC.P.REV.MED./Min/4 Page 11 Manila, a city with 1.5 million population in 15 square miles, was divided into 35 health centres. The public-health service in the city took care of Manila

the lower strata of the population not individually, but by families.

was divided into four congressional districts with around nine centresin each district staffed by doctors, nurses, social workers, sanitarians, and other health workers. Each visiting nurse was assigned an average of three to four

blocks and was in charge of all members of the families deserving government aid. In accordance with the programme of these centres service was given long In fact serological exagination and medical examination Manila was particularly Marriage

before a baby was born.

were carried out prior to granting of marriage permits.

fortunate as the City Health Officer was also the Civil Registrar.

licenses were not issued until after medical and serological examination,and with these a pamphlet on general health was also distributed. Young couples of the

centre were advised where they should register, and were briefed on the different health services in the city. centre every week for until school age. threemonth~then

A newly born baby was brought to the every six months and later once a year

Nurses visiting homes did not stop at inspection of mother There was a pilot project

and baby but looked over every member of family.

in an area where the names of all members of the family were set out on a card and all the members of the health centre staff gave their opinion on the state of health of the individual member of the family. There were regular

mothers' classes, classes in nutrition and economics, etc. A department like this would appear to require a large staff but personnel was limited. Shortcomings in staff were complemented by ladies associations

which take care of recruitment of mothers and families, raEedfunds, acquisition of sites for centres,etc. Contact was

WPRO/SOC.PREV.MED./Min/4 Page 12 Contact was maintained with private and publicbospitals and medical associations who gave one or two hours a week for cases beyond the competence of the regular centre staff. There was also close contact with other agencies

such as the Red Cross which was in charge of allocating blood. Dr. GRZEGORZEWSKI stated that he thought one element was lacking and that

was the mention of the proportion of needs met to the needs established and the degree of "saturation" of the community with medical and health r~sources.

Professor LLOYD DAVIES stated that one point in Dr. Icasiano's talk had caught his attention and that was the apparent infringement of personal liberties. He asked how the personal liberties of the family were maiutained. Dr.tICH"E:NWALNER was of the opinion that with th~

exception of the first

presentation all the speakers had described situations which were completely outside the role of social and preventive medicine. He would be particularly

interested to hear of the role of the department of social and preventive medicine in the comprehensive health care rather than specific examples of health care given by governments or industries, etc. Dr. SMITH drew attention to the fact that this was 6

study group on the

teaching of social and preventive medicine and not on the organization of a medical health service. annotated agenda. Re item 6.2, the basic question to be studied was what were the needs of the community in terms of comprehensive health services arnwhether these would be developed by government or private agencies, these principles had to be in front of future doctors preparing to meet total health needs. There was He referred in this connection to item 6.2 of the

a danger in the teaching of medicine to teach far too much how to diagnose and treat illness. The area of interest was much wider than this and covered the health •••

WPRO/SOC.PREV.MED./Min/4 Page 13 the health of whole communities. on how to provide these services. Students should have principles to guide them Dr. SMITH stated that he was not suggesting

that comprehensive health services were the only answer to thiS, they were not, they might be suitable in some cases and not in others. It was necessary,

however, to be prepared to analyze the requirements of comprehensive health services, conduct research of needs of the system and place before students principles which would guide these thoughts. Re item 6.3 - comprehensive health services could give students sound training in all branches of health care - the organization of such services, relation to health budgets of countries, relation to resources of the countries, etc. When one agency took upon itself certain phases of the comprehensive health servioes, other agenCies absolved themselves of such responsibilities. There was a

danger where a university and teaching school provided any kind of comprehensive health service that the other agencies felt absolved from such provision. Dr. GRZIDORZEWSKI did not think that the discussion had deviated from the

•

agenda.

He felt that the speakers had given valuable information some of which

he hoped could be included in the final report. After discussion, it was agreed that the item would be further considered in groups if they wished so and the results of their deliberations would help the secretariat decide if this item could be continued as a special interest item. The meeting adjourned at 3: 30 p.m.

WPRojSOC.PREV.MED.jMinj4 ANNEX I

! HEAD OF THE HOSPITAL I____________ T ____--__ ~

CLINICAL

MEDICINE , ,~----------~

1+ \

DEPT. OF ,t' HEALTH GUID.Al'·,!CE ~'--~==~~~.

- - --.------

CEi·!TP..AL 1 FHA.Rl:IACEUTICAL·r IADl.iIIITSTBATION UNIT IABOHATORY. ! 1 I . UNIT _. '

~qy

HEALTH GUIDANCE UNIT Health Counseling Unit Eugenic Counseling Unit Industrial Health Unit Geriatric Unit Home Extension Unit 1iiedical-social ',.ark blental Health Unit ::jell Baby Unit

q,,~ * * i!-3~

I /'

I> ~.§ 0

q,,' if-

if-

ifI

f' if-

* i~-

* ;.

WORLD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL

REGIONAL OFFICE FOR THE WES'J'JIRN PACIFIC

WPRO!SOC.PREV.MED.!Min!5 Corr.l 28 October 1957 ORIGINAL: ENGLISH

AND PREVENTIVE MEDICINE ~nl1a,

Philippines 16-29 October 1957

MINUTES OF THE PLENARY SESSION ON AGENDA 5

Corrigendum Page 3, paragraph 1, lines 2 to 5 Please delete the following text: "It was his understanding that all teachers preferred integrated courses but did not know how to conduct them particularly with respect to certain subjects where integration came with difficulty." and insert as follows: "It was his understanding that all teachers preferred integrated courses but they were still experimenting how to conduct them, particularly with respect to certain subjects Where integration came with difficulty."

,--,

WCRID HEALTH ORGtJUZATION STUDY GROOP ON SOCIAL AND PREVEmIVE MEDICINE

REGIONlU. OFFICE FCR THE WESTERN PACIFIC

WPRO/soc.PREV.MED./Min/5 24 October 1957 CRIGmAL • ENGLISH

Manila, Philippines

10-29 October 1957

MINUTES OF 'lliE PIENARY SESSION ON AGENDA 5

Institute of Hygiene

Wednesday} 23 October 1957 at 8:30 a.m. CHA:mMAN: Prof'essor E. S. Monteiro CCNTENTS

Discussion of Group Reports - Group I Group II

•

WPRO/SOC.PREVJMED./Min(5 Page 1

The CHAIRMAN stated that the plenary session was convened to discuss item 5 of the 'agenda, namely the relations beween the department of social an:i preventive medicire and other departments of a ~dical

school.

Report of Group I Dr. MATTHEWS reported for Group I. Professor LIDYD DAVIES, Chairman of Group I, stated that the recorder had very.fully and adequately sUI1l1l8.l'ized the discussion and that he would He introduced to

confine his remarks to the highlights of the discussion.

the meeting Dr. Matthews l very vivid term of "elevator medicine" by which was meant the members of the staff who joined the department and presently were elevated wi thin the d~partment,

as for instance from assistant lecturer The

to lecturer without having had arv experience outside the department.

term "elevator medicine" very well described this sort of situation which was very common. The second point he wanted to introduce was the statement

that too marv non-medical personnel in the pre-clinical years had led to segregation. Doctors were rather notorious for pushing around non-rmdical clique and such matters did lead to

people who quite naturally form a segregation.

The answer was that there must be some non-rmdical people in

a medical school who should be regarded as closer colleagues than they were regarded in the past. He stated that the group did not finish the discussion

of inter-personal relationships between members of a medical school.

People had their own personalities and marv of the difficulties of co-operation arose from differences in personality. '-

It may be possible to

examine the •••••

WFRO/SOO.PREV.MED./Min/5 Page 2

examine the personal relations within the medical school. difficulties arose from insecurity.

It was felt that

The head of a department, not fully

secure himself, may exhibit vani1:¥ or pride and was so for historical reasons and perhaps from overwork. Some members felt however, that overwork was an excuse rather than a reason. A suggestion had been made that the

dean should solve these problems but that would make the dean into a superman, certainly a very unfair burden to the dean. At another stage,

it was suggested that the dean should compel co-operation in such endeavours as joint ward rounds or joint research work. lbis suggestion was :i.rnroodiately

disposed of because once "compulsion" was used, one was back where he started. Report of Group II Dr. CHEN read Group II's report. '!he Chairman of Group II, Dr. KUSAl1A., stated that agerxJ.a , had been discussed very lengthily and consequently the recorder had summarized the discussion in a short and concise way. further to add to the report. The CHA.IRMAN thEn stated that the matter was now open for discussion.

He did not think that he had an,ything

He added that a point of interest was the problem of integration of medical courses, and its relationship with the possible co-ordination of social medicine within the study of integration. He talked of the prograrrme at the

Universi 1:¥ of Malaya where he stated the programme of integration was not working satisfactorily. Professor IJ.oyd Davies •••

.... • WPRO/SOC.ffiEV .MEn ./Min/5 Page :3

Professor LWYD DA.VIES spoke of tile experiment at the Universito'" of Malaya which had been started two years ago. It was his understarrling that

all teachers preferred integrated courses but did not know how to conduct tilem particularly witil respect to certain subjects where integration came with difficulty. of the subject. Few found integration to fit in with tile chronological order He gave the meeting details of tile programme. He pointed out

the fact tilat integration required a tremendous number of meetings ani discussions between the staff. these in Singapore. He did not tilink there had been enough of

Unless that was done., it would be found that wi thin a

short period the staff members would be repeating tile same thing and the students consider this a waste of time. The students did not mind repetition He stressed that what

after six months but not when it came within a week. he had just stated were his own personal views.

The CHAIRMAN asked whether an;yone would like to speak on integration. Dr. SMITH quoted a remark made by Dr. LiIRA on co-ordination between staff members which he tilought should be put on record, that old men liked

to learn rut they did not like to be taught. The CHAIRMAN referred to the role to be played by tile dean in the matter of co-ordination with other departments in the medical school. He

thought that the dean should never be asked to use compulsion ani t1B t no dean should resort to that. He believed co-ordination with other departments He also

could be obtained by good leadership and policy in tile school.

believed in the goodness of men and their reasonableress tilat there should be no difficul~

••••

.....

WFRO/SOC.PREV.MED./Min(5 Page 4

be no difficulty in persuading them to do the things they have to do. '!here might be different personalities, but it should not be too difficult

for people to listen to sound reasoning. There was no further discussion

Dr. MA. reminded the group that the

field visit in the afternoon would start at 1:30 p.m. The rooeting adjourned at 9:15 a.m.

.,;

I«>RLD HEAL'lH ORGANIZl. TION

REGIONiL OFFICE FOR THE WESTERN PACIFIC WPRO/sOC.PREv.MED./Min/6 28 October 1957 ORr GINAL: EN GLISH

AND

S lUDY GROUP ON SOC I1J, PREVENTIVE MEDICINE

Manila, Philippines 16-29 October 1957

MINUTES OF THE. PLBNARY SESSION ON AGENDA 7 Saturday, Insti tute of October 9 Professor 'lbmio Ogata

CHAIRMAN:

CONTENTS Page

1 2

PRACTICE FACILITIES AND COMMUNITY RESEARCH OF THE DEPAR'lMENT OF SOCIAL AND PREVENTIVE MEDICINE THE RIZAL PROVlliCE INTEGM TED PUBLIC HEALTH PROGRilMME 1l.NNO UNCEMEN 'lS OTHER BUSINESS

4 6

WPRO/SOC.PREV.MED./Min/6 Page 1 1 PRACTICE FACILITIES lJID <DtMUNITY RESEARCH OF THE DEPi.RTMENT OF SOCIAL AND PREVENTIVE MEDICINE

The CHAIRMAN stated that the neeting -was convened to discuss agenda item

7, namely practice facilities and community research of the department of so cial c.nd preventive medicine. Before aacirg forthu :group reports"he annoWlced that Group II had discussed su1>-item

7.5

as another Han of the agenda, namel3"

The reports of Group I and Group II 'Were given by Professor LLOYD ill. VIES and Dr. LICHTENWJ.LNER, respectiveJ,y. TheCHAIIMAN called on the chairman of each group for comments. ProfOssor LLOYD DAVIES, speaking as chairman of Group I, stated that it seemed to him that an inq)or'iant point discussed 1U his group was the difficulties of some schools in SOIlJ3 countries in achieving cOo-ordinatio n, or even ca.-operatiCl'l, between the Ministry of Education, which controlled IlJ3dical schools, and the Ministry of Health which controlled hospitals. An allied point to the ore just unive~

mentioned was the discussion on the autonomY of the university, that the

siW and its medical school should be entireJ,y free of political control even when funds were provided directlJ" or indirectly or derived from governments. Professor LLOYD IliLVIES suggested that the study group strongly deplore situations which W3re a hindrance to co-operation between medical schools am health ~

services, and to deplore any interference with the proper functions of a universi1:iV. Dr. EDMONDS congratulated the rapporteur of Group II for the excellent job of recording the salient points of discussion which were extraooly diffuse. He thought that towards the end of the discuss :ions, the group felt that the real effect of the teaching of social am preven tive IlJ3dicine was particularl3" mani.fested in the application of cOJ1llllUl1ity health services to students. In

the first agenda •••

WPRO!SOC.PREV.MED./Min/6 Page 2

tpe first agenda item discussed by the group, it was agreed that one objective . of the social am preventive medicine departnent should be to make the doctor conscious of his place in the comnuni ty, his privileges and responsibilities .., It would therefore appear that in using community health services in teaching social am preventive roodicine, there were two objectives in view - one was to impart information and ihe other was that sonewhat nebulous objective of creating impressions and ~oducing

attitudes, 0

Ever present msthe triad of the

host (the student), the agents (departroont

f social and preventive medicine) and

the env:ironrent (the atmosphere to which stUdents are exposed).

In some surveys

of the effects of the use of community health services in the United states, it was found that students reacted various~

to the situations met.

If there was

aqy conscious desire in producing a desirable attitude by exposure of stUdents to environment, the attitude should be that of being able to attack problems on a scientific basis. III

Students should

be carried away too much by

emotion but should

et problems

scientifical~.

Dr. Grzegorzewski observed that there w as general agreement asto'lhe useful.. ness of field visits. them as students. H e requested the group to recall how such visits affected

Such tours were unworthy when ihe old practice of collecting

about a hundred students and during a visit fully exple,in details to only about five 01' six was followed. The purpose of such undertakings vias lost rod some Field visits should be well planned and

students were actually antagonized.

organized and one important element should be considered - it would take them out of the limited environment of the classroom into one which we.s broader. Dr. Grzegorzewski ~eed

vast~

with Dr.LLOYD

Di~VIESI

opinion on autonoll\1 of the This

university and requested that the group should be clear on one point.

point should •••

WPRO/SOC.PREV.MED./Min/6 Page 3 point Should apply not only to universities but also to all other educational institutions that may not be part of a university but form a university by themselves. Sir CHARlES HERCm, commenting on the opinions of the groups on autonorrw,

raninded the group that the university was the centre and home of the medical schoo~

He, appreciated the political practices in the different countries and

recommendedthat political and financial control should be given back to th3 canpus as quickly as possible. The essence of the university was :Ln universaliiy.

Regarding the report of Group II, he reiterated previous opinions that active participation W!lS

the essence of teaching. w~

One' could not be t.:lUght medicine

but he could learn it and the best

was through active participmtion.

Dr. LLOYD D!.VIES stated that there was a traditional list of places for

undergraduate students to visit and this included water treatment sewage facilities etc. He statod

plants,

which he did not think were valuable to the studenta.

that visits should be made to installations or facilities with a

human being centredin them.- 118 an example, he gave a country where a safe water supply was of primary inportance. ,l.

visit to this facility was permis-

sible not to see the engineering marvels etc. but to show ihe effect of such facility on public health. Dr. KUSILM:. stated that thE) agenda item was discussed on the basis of communities which had. more or less organized facilities -available for teaching purposes. His univer)'sity had gone a step further in utilizing communities

with no facilities vila tsoever as part of the teaching programme for m9dical students. During summer for the mst severnl. years the university had been

sending a health care and welfare team composed of volunteer students aided by three clinicians am. an adviser from the social am. preventive medicine department. ••

WPRO/SOC.PREV.MED./Minj.6 Page 4 department to remote communities of about 500-700 popul~tion. These communities

had no contact whatsoever with modern medicine and their welcome and co-operation was more highly stimulating to the students than n visit to established health se~vices.

community with

In reply to Dr. DEl'IPSTER's question, Dr. KUS':.M.::" said that the students

paid their share of the

expens~s,

the University gave 50,000 Yen, private phar-

maceutical firms supplied medicine, drugs and supplies and the hospital lent equipment during such visits. Dr. NOBECHI stated that this had also been a practice in his university during the past five years. 1. priv."~te

newspl1.per publishing firm gave the school

400,000 Yen annually and the Government paid for any additional expense involved. Dr. tMITH,coIllIlEnting on Dr. LLOYD Dil. VIES' stlltement on the desirability to decrease visits to public works services such as waterworks, etc., felt that students could benefit from visits to these facilities. 1heir bacrkground on

the chemistr,y involved would impress upon them the importance of these facilities on public health and the price of which was eternal 2 vigil~nce.

THE RIZlJ. PROVINCE INTEGR.:.TED PUBLIC HEi.LTH PROGR.:.MME 'll1e Clli..IRMI.. N announced thRt as a special feature of the P :Lenar,y, a short

talk on the Rizal Province Integrated Public He'Clth Progr'lmme would be given Qy

its operational officers. Dr • .i:.MrlNSTh M..'.NGAY, Chief of the Rural Heo.lth Demonstration and Training

•

Centre, Quezon City, introduced Dr. Balbin, Project Directur of the Rizal Integrated Public Health Progr~e,

...

and Dr. Nolasco, Director of the Bureau 1uestions regarding the administration of

of Health, who would reply to any the project.

Dr. B..LBIN began •••

.. WPRO/SOC. PRE V.MED.jMin/6 Page 5

Dr. BlJ.BIN began his talk by explaining that the proposed integrated public health progranme for the Province of rti 213.1 had been in the planning stage for the patlt two years andoooaolidation of these plans had been accomplished during the past two months with the creation of a special technical comrni ttee appointed by the DepartllBnt of Health. joint approval of Riza1.. The main objectives of this progranme were the improvement of health services in Rizal province, the establishment of a proving ground for practical procedures for implementation of public-health progranmes, provision of a training centre for various categories of public-health workers and a ground for exposing students and workers to the field of public health. It muld be implEJllented upon

qy the Department of Health and the Provincial Health Department

It muld

also serve as an adequate field £acility for foreign public-health students and oooervers. 'ilie province of ilizal was selected due to its typical geogra-

phical and socio-economic eharacteristics, its dis'nnce and accessibility to Manila, the interest and enthusi:lsm i 0

f the n". tional governm6nt and provincial

officiaLs ani the financial status of the province, which a ssured continued support for the improvement of services and the maintenance of the training area. It was planned to hnve this project under the direct ~dministration

and

supervision of the provincinl health officer '1110 would be responsible to the Department of Health for both curative and preventive services at the provincial ~nd

municipal levels.

hgencies participating in.this programme were the Department of Health, RiZal Provincial'Health Department, the Bureau of Health, the Bureau of Hospitals, the Division of Tuberculosis, the Division of Laboratories, and

the Division of Personnel Training, Health Education and Information of

~he

Dep2rtment of Health, •

WPRO!SOC.PREV.MED.}Kin/6 Page 6 Department of Health, the Institute of Nutrition, Institute of HYgiene and other government agencies. It was also expected to have technical assistance from The commitments of these agencies were

foreign and international agencies.

embodied in the operational details agreement. The administrative structure of the integrated public health programme was explained through the use of a Dr. L1~ cht~rt •.

added a few personal sidelights on the project and stressed that

this project v.ns the htest endeavour in the field of practical experience for medical and public-health students. It was hoped that the results of the study

group would help in solving some of the problems or suggest approaches to this end.

.I\.NNOUNC:EMENTS The ~ecial interest groups were invited to continue their discussions

,' ,

and additional suggestions on special interests were reques ted. Malacanan Palace was being plm ned for Sund1V.

.i. visit to

un behalf of the Study Group, a cable had been sent to the Japanese Public Health •• ssociation congratul.ating them on the opening of their 12th ...:.nnuaJ. Conference • . "!be meeting was informod that items 8 and 9 of the ."genda HOulcl be discussed in plenary session on Tuesday lOOming. session. There would be no closing

OTHER BUSINESS

Dr. LLOYD DAVIES requested that lines 2 to 5 on page 3 of WERO!SOC.PRKV~ED.JMin/5 be ameDded to read "It was his understanding that

all teachers preferred integrated courses but they were still experiInenting

how to conduct •••

·.

VPRO/SOC.PREV.MED./Min/6 Page

how to conduct them, particularly with respect to certain subjects where integration came with difficulty." ']he statements in the second paragraph of page were made l:u Dr. MUR.R1l.Y instead of Dr. Edmonds. The meeting adjourned at 10:15 a.m.

5, lti>RO!SOC.PREv.MED./Min/3

,. WORlD HEALTH ORGANIZATION STUDY GROUP ON SOCIAL AND PREVENTIVE MEDICINE ManUs, Philippines 16-29 October 1957 REGIONAL OFFICE FOR THE WESTERN PACIFIC WPRO/SOC.PREV.MED./Miq/7 5 November 1957 ORIGINAL: ENGLISH

MINUl'ES OF THE FINAL PLENARY SESSION

Institute of aygiene Tuesday, 29 October 1957 at 8:30 a.m. CHAIRMEN: Dr. Keizo Nobechl for Part I Sir Charles Hercus for Part II CONTENl'S PART I 1 Plena~

Session Programme ••.•••.••••••.•••••••••••••••

Reports on the Special Interest Discussion Groups •.••••••••••••••••••••••••••••••••••• 1 1

Teaching iIi Rural Health Teaching in Urban Health Cultural Studies

•

...................... ...................•.. ..............................

2 4

:3 4

Report on the General Evaluation Questionnaire •..••••••••••••••••••.•••.•.••••••••••••

7 7

Future Planning

....................................... PART II

Closing Remarks

.......................................

ANNEX I

Returns of Study Group General Evaluation Sheet

WPRO/SOC.PREV.MED./Min/7 Page 1 PART 1 PLENARY SESSION PROORAMME The CHAIRMAN announced that the agenda items origina~

sCheduled

for that morning and afternoon, namely final discussions, future planning, . general evaluation and the closing session, would be combined into one plenary session to be completed that morning. In addition, brief reports The item, summary

of the special interest discussion groups would be made.

of diSCUSSions, would be omitted from the present agenda as participants were in possession of the final report in English. The same report in He

French would be sent to Cambodia and Vietnam as soon as it was ready. asked if there were a~

questions or cOlllllents with respect to the report.

There being no questions raised or comments made with regard to the report, the CHAIRMAN then aSked for the reports of the special interest groups. 2 REPORl'S ON THE SPECIAL INl'EREST DISCUSSION GROUPS 2.1 Teaching in Rural Health Dr. THIEU reported on behalf of the Special Interest Group on

"Teaching in Rural Healthft

•

He stated that the session had been attended

by the partiCipants from Cambodia, Vietnam, Korea and Japan, and also by . Dr. Lichtenwalner, Vietnam, and Drs. Shu, Falkland, and Shiga of WHO as resource persons. Taking advantage of the presence of the latter, the

group, before proceeding to the subject of the meeting, had asked and were informed of the possible approaches for obtaining assistance fram agencies sueh as lCA and WHO for countries like Cambodia, Vietnam and Korea. The group •••

" WPRO/SOC.PREV.MED./Min/? Page 2 The group discussed the types of work and study conducted in health centres in Japan where, according to Dr. Shiga, curative work had been combined with preventive medicine in all rural centres. The group also discussed the programme organized by Dean Kusama on the study of preventive medicine by medical students through rural health. This also served as a means of alleviating the shortage of technicians. This programme, which Dr. Kusama had also the opportunity to explain during one of the plenary sessions, was a voluntary undertaking by medical students during their summer vacation. Dr. Meynard had been very enthusiastic about

•

this movement and thought that although the background in Japan and Cambodia differed, changes could be made by asking help from WHO to supp~

technical

assistance in the form of teachers, lecturers and public-health officers, and funds.

Dr. Falkland had promised to study this proposition.

Other parti-

cipants had reported on similar voluntary activities of medical students going to various rural health centres to help as well as study preventive medicine work in their respective countries, but unlike Japan the movement was not channelled and organized through the academic Department of Social and Preventive Medicine. ,The group recognized the need for a sound basis of approach and it was agreed that techniGa~

the programme should be guided

by the Department of Social and Preventive Medicine. 2.2 Teaching in Urban Health Dr. SMITH reported that the Special Interest Group on ''Teaching in Urban Health" had met under the chainnanship of Professor Ogata. general the group had not considered specifical~

the question of teaching but. preferred •••

)

WPRO/SOC.PREV.MED./Min/7 Page 3 but preferred to consider problems of urban health generally. Discussion

had opened with the decision to consider housing as the most important urban health problem in the Region. Two factors were considered important

in housing, namely town planning and house construction. Town planning was considered to be the primary question. Health

considerations relevant to town planning were mental health, healthy growth of children, and prevention of accidents. There were many problems. Firat

among these was that population pressure made provision of shelter of primary urgency. Should apartments or houses have first consideration?

Space limitations usually indicated apartments but these had unsatisfactory features. It had been noted by one member that children from flats tended to Lack of play space might be an important factor.

be more aggressive.

If houses were preferred, these might be more expensive and farther from the place of work. These factors combined to use a large part of tenants'

income in rent and transport costs and nutrition often suffered as a result. Location of housing in dense traffic areas increased the risk of traffic accidents. Accidents were an increasingly important cause of death, and now of death in Manila.

featured among the ten commonest cauSes

Proper design of apartments could liberate ground space for recreation. At a given density of persons per acre flats offered more open

ground space than houses. Many housing projects suffered from being too costly for persons who needed housing. Lack of central control of building and lack of consulta-

tion with health departments were largely responsible for housing programmes failing to meet real needs. Of course •••

" WPRO/SOC.PREV.MED.!Min!7 Page 4 Of course, to meet these real needs was often beyond the resources of the community. It was difficult to see how such a problem could be solved. careful~

Housing structure needed to be planned resources well in mind. features.

with needs and

Shelter, drainage and water

supp~

were paramount

The age structure of the population should be considered.

For

example, most cities in the Region have a much higher proportion of children than was usual in the West. Health departments should always be represented on policy-making bodies concerned with housing and town planning.

2.3

Cultural Studies Dr. REGALA reported that the Special Interest Group on "Cultural

Studies" had Dr. Kilborn for its chairman.

The group had considered cultural

studies in relation to better understanding of students, patients and communities. It had defined culture as inter-personal~

transmitted wqys of living

in respect to habits, behaviour, customs, traditions, law, religion and systems of education. Methods of teaching and content of courses affected An overcrowded curriculum did not give Didactic methods, spoon-

the ability of students to think.

time for thoughts and reading of the literature.

feeding or hand-outs in teaching and the manner of asking questions in the examination might develop among stUdents a catalogue mind. per teacher were also an important factor. Too many pupils

In certain cultures authoritarianism -

the authority assumed by or vested in seniors or elders, the restrictions imposed upon younger ones which were brought up in the home enviro~ent

- were

reflected by teachers in teaching and by stUdents in learning.

These attitudes led to •••

WPRO/SOC.PREV.MED./Min/7 Page 5 led to reliance on accepted authority and did not encourage the development of initiaitve such as frequent use of library facilities. The group felt

that hand-outs in teaching need not be abolished but modifications of such methods would be desirable. Consideration had been given to culture based

on philosophical or speculative ideas on the one hand and pragmatism or factual emphasis on the other. The former lacked precision and the latter

lacked imagination. Where culture was influenced qy the sacred or the great books, it tended to be more philosophical. ideals were more practical. Where this w~s

not so the

On the whole, university students were not aware

of existing cultural patterns and might be shocked on first learning them. They might despise the uneducated. This observation led the group to ask st~qy

whether or not pre-medical students should be required to knowledge of cultural patterns.

or have a

Language problems presented difficulties such as when teaohing was given in one language and the textbooks used were written in another language. Awareness of differences between the local culture and that of the Furthermore, considera-

country of origin of textbooks was perhaps important.

tion should be given to the traditional system of medicine and of the effects or influence of nationalism. It was recognized that culture varied in It could and did affect concepts

different places and at different times.

of health and disease and medical practice. On the topic of hierarchy in hospitals, an example was given where restrictions existed with respect to visiting hours and patients! association with their families. The use of pqying or private patients in (This was usual in

hospitals for teaching purposes was also mentioned. western cultures but not in eastern cultures.) \

The group •••

WPRO/SOC.PREV.MED./Min/7 Page 6 The group then considered certain practical measures which might be applied to mitigate the influence of cultural patterns in methods of teaching and learning: training of teaching staff through group discussions among

teachers in related fields, small-size classes, emphasis and strengthening in the teaching of the exact sciences 8~ch

as mathematics, etc.

Modifications or changes in culture (e.g. converting a need into a want) had been viewed from the standpoint of additional responsibilities that might arise such as increase in population as a result of malaria eradication. It was felt that the time-honoured objectives in medicine and public

health should be pursued in the confident expectation, already shown in some countries where changes had occurred, that socio-economic problems that might arise could adequately be resolved. There was need for a revision of the II

traditional system of medical ethics to extend the responsibilities of the doctor beyond the individual patient to those related to the community as a whole. Dr. MA added that some consideration had been given by the group to conununiW development projects in which health was an integral part of the overall programme. Dr. HAMCS refeITed to a statement in Dr. Regala's report. (the students) might despise the uneducated." rather strongly worded. "They

He thought this statement was

Dr. KILBORN recalled that the original statement was meant to indicate that the student might despise the uneducated partly because he was so completely divorced from the type of thinking that the uneducated person indulged in. His customs J traditions, etc., might be entirely foreign to the

student although the stUdent was of the same raoe or nationality as the uneducated patient. Professor •••

WPRO/SOC.PREV.MED/Mln/7 Page 7 Professor LLOYD DAVIES remarked that the word ~educated

in this

context should apply to those not subjected to formal schooling. The CHAIRMAN announced that the other groups such as that for clinical studies and visits to various institutions would not give aqy report. He then asked Dr. Ma to give a report on the general evaluation questionnaire.

REPffiT ON THE GENERAL EVALUATION QUESTICNNAlRE

Dr. MA reported that 26 completed questionnaires had been returned to him.

He summarized the opinions expressed in the questionnaires. (Annex I) Dr. MA stated that a long list had been given under question 18 which

asked for frank criticisms and suggestions for the study group which would aid in the planning and operation of future meetings of that nature. Although

he did not read to the meeting all the suggestions and criticisms given, he assured that all of them would receive serious consideration by the secretariat and the Regional Office. The CHAIRMAN thought that the diverse answers were natural due to the different backgrounds and conditions in the home countries of the participants. However, the answers to the questionnaire in general seemed to indicate that the participants had profitted greatly by the study group meeting. Dr. SMITH singled out the comment that all the books in the library except one were American and stated that actually there were one Belgian and fourteen British books (including two Canadian) in the stuqy group library. 4 FUTURE PLANNING

The CHAIRMAN informed the group that there were two aspects to the topiC, namely first, what did each participant plan to do upon return to his country with respect to the strengthening of teaching of social and preventive medieine •••

WPRO/SOC.PREV.!-1ED./Min/? Page 8 preventive medicine in his own medical school as well as in other schools not represented at the study group, and second, was there a need for another stu~

group in the future?

If so, should it be on the teaching of social

and preventive medicine or on some other topic? Dr. MATl'HEWS spoke for his colleagues· from Korea and stated that their plans upon return to Korea were to review the agenda and records of the discussions as well as the final report of the study group with the faculty members of the Seoul National University and to develop a plan for integration as soon as possible~

It was also intended to report the results of the

•

studT group to the Ministry of Education and to the Ministry of Health and Social Affairs in the hope of being able to subsidize the plan suggested by the study group. Dr. REGALA stated that he was not connected with any medical school in the Philippines but he wished to suggest that it might be helpful i f the report of the study group and possibJ.,y records of the proceedings could be distributed to the medical schools not only in the Region but to other countries where medical schools did not have social and preventive medicine. Dr. KUSAMA pointed out that his delegation represented onJ.,y three out of forty-six medical schools in Japan. They however planned to disseminate well-developed departments of

•

the knowledge and experience they derived from the study group through the powerful Japanese Public Health Association whose membership consisted of the teaching staff in this field at all medical schools and other experts. This association had close co-ordination with the Ministry of Health and Welfare. Dr. WEI •••

WPRO/SOC.PREv.MED./Min/7 Page 9 Dr. WEI stated that there was at present only one civilian school of medicine in Taiwan, but a new one was being established in the southern part of the Island. He intended to bring the ideas obtained during the study group

meeting to the faculty of the National Taiwan University College of Medicine and to ask them to pay more attention to the social and preventive aspects of medicine and to impart these ideas to their students. He would also ask the At the moment,

faculty to consider integrating some of the courses given.

there was a lack of field training facilities for undergraduate medical students and graduate public-health students, but negotiations were being conducted with the PrOVincial Health Administration to secure co-ordinated and controlled training centres for the medical school. Dr. HURRAY thought that the study group would be most useful to their school from the point of view of the training of pos~graduate

stUdents.

They

already had reasonably good courses for the undergraduate students and the meeting had given him a much better understanding of the requirements of areas from which fellowship students were sent by vlHO and other agencies. Dr. TUAT thanked the study group sincerely on behalf of the faculty of the School of Medicine in Saigon for the excellent facilities of WHO am the eminent participants who, during the meeting, had shared their knowledge and experiences on social am preventive medi~ine.

Upon his return to his home

countr,y, he would.endeavour to implement the programmes discussed by the study group by convincing his own colleagues first.

Dr.

EDMONDS felt that the study group had been of more value to him His was a very small medical school in a very small part of the world •••

than t.o many.

.. WPRO/SOC.PREV.MED./Min/? Page 10 the world where it had been desired to teach social and preventive medioine to students. The stage had been reached where -teaching was being formalized His

I ,

and it was hoped that an independent department would soon be started.

attendance at the meeting would enable him to start the department on a reasonably sound basis and he was sure that many mistakes would be avoided. He expressed

his appreciation to the secretariat for its help and to his more experienced colleagues who had contributed to his small surn of knowledge.

Dr. KILBORN intended to report the findings of the stuQy group to the authorities in Hongkong on his return and he hoped that it would strengthen their endeavour to secure an increased university grant from the local government authorities for a full-time staff in the department of social medicine. The faculty of medicine was quite aware of the needs of such a department, but an increased government subsiQy would be required. He felt that that this

•

stuQy group and its findings would help the faculty to convince the authorities to make that grant. Dr. LARA felt that villO had done his institute a great service by holding the stuqy group meeting in Manila. He gave the assurance that the ideas that

had emerged from the meeting would find a fertile ground in which they could grow. It was planned to mimeograph the proceedings arxJ. distritute then to of Medical Schools in

various medical schools through the Council of Deans the Philippines.

Sir CHARLES HERCUS stated that there was no perfection in human affairs and there were still many unsolved problems in New Zealand even though it had made progress in certain directions possibly more quickly than others. Concerning the •••

.. WPRO/SOC. PREV. MEn. /Min/7 Page 11 Concerning the study group, he was sure that with Dr. DEMPSTER they had learned a great deal about the cultural patterns of the countries represented and that they both would return to New Zealand with a great deal of information which they did not have previously, as well as of friendship which was of immense importance to them. They also shared Dr. MURRAY's feelings in that

they could do more to assist in the post-graduate education of students from other areas. As far as future planning was concerned, Sir CHARLES felt that the spirit

•

of the He

stud¥ group had shown that the underlying prinCiple was integration • felt that the next step would be closer consultation with clinical A meeting after about

persona~

colleagues in the practical problems of integration.

five years was deemed ideal when the group could have a stock-taking, reviewing progress and taking courage from one another. The stuqy group had learned a great deal from one another and it had defined some of the fundamental principles which would be taken back and infiltrated in a thousand ways in each respective culture, not only through the medical faculties and government with the citizens of each country. Dr. LLOYD DAVIFS agreed with Sir CHARLES that five years would be agencies~

but in the

day-to-d~

contact

desirable before stock-taking, but personally felt that prior to such a subse\,

quent meeting, there was need for more factual information.

He felt that the

most valuable suggestion made by the group was that for a comparative study of the medical schools in the Region with particular attention being paid to the development of such schools relative to the development of their ccmmUnities. With this comparison, WHO would be able to group the countries and organize smaller meetings which would be more useful. Regarding •••

WPRO/SOC.PREV.MED./Min/7 Page 12 Regarding Singapore and Halaya, Dr. LLOYD DAVIES had conferred with Dr. MONTEIRO before the latter's departure and they intended to make a fundamental examination of the curriculum at the University of Malaya. Although

the University was bound by the General Medical Oouncil regulations, it might be possible to integrate the clinical and pre-clinical parts of the teaching and it was thought that this was where social and preventive medicine could come in. Dr. OGATA reminded the group of the second world conference on medical education which would be held in 1959 and wondered whether the next study group

• meeting could have some connection with that conference. He agreed with Sir CHARLES and Dr. LL01lD DAVIES that the subject for the next study group should be on post-graduate teaching because he understood that the interest of the second world conference on medical education would be in that area. Dr. LARA felt that there were ma~

problems that interested everyboqy

and thought that the suggestion to hold a conference on medical education as a whole was a sound one. This conference should stress integration am co-ordination.

It should also touch on the employment of the facilities of various departments for the teaChing of prst-graduate students in medicine. Dr. MATTHEWS stated that Seoul National University was distinctly interested in the results of the fact-finding project suggested by Dr. LLOYD DAVIES and thought that after this, a study group composed of people interested in fundarental medical education to discuss the minimum requirements of redical schools, curricula, faculties, faCilities, etc., would help improve the position of the physician in the community, sibilities. particular~

in regard to his social respon-

It was felt that such a stuqy group should involve disciplines other than •••

WPRO/SOC.PREV.MED./Min/7 Page 13 other than social and preventive medicine since the present study group had successful~

polled the opinion of the group. particular~

Dr. KILBORN supported the views of Dr. MA'ITHEWS,

on the

inclusion of other aspects or disoiplines in the field of medical education in future conferences. He also expressed the hope that a conference could be

held on the pre-olinical departments of medical schools.

Dr. MA'ITHEWS stated that one of the most important contributions in the study grbup was the opportunity for deans to gather and it was strong~

suggested that WHO should involve deans of medical schools as well as professors in all future conferences or study groups of this nature. by Dr. LARA. Dr. IGASIANO recalled that mention was made of the necessity of utilizing local health departments in the teaching of social and preventive medicine and he believed that future meetings on the teaching of social and preventive medicine should include health officers. Dr. KUSAMA believed that the objectives of teaching social and preventive medicine were to teach undergraduate students as po·ssible future public-health personnel and to make future doctors public-health minded. As the members of This was supported

the present study group were responsible one way or another in carrying out these objectives, it was therefore more appropriate for the group to get together in the future and discuss the same subject.

PART II

WPRO/SOC.PREV.MED/Min/7 Page 14 PARI' II

CLOSING REMARKS Sir CHARLES HERCUS, Chairman of the Planning Committee, stated that II

technological advances of the present remarkable age had, with the help of WHO, brought the group together over such a widely-dispersed region of the world. These technological advances in scientific medicine had definite~ .>

outrun the social and preventive responsibilities of medicine. was indeed international.

Great medicine

There were no national boundaries in any aspect of

medicine and it was abundantly clear that members were all bound together in close bonds of profession and of ideals whatever the cultural background from which they came. The objectives and ideals were fundamental~

the same and

this had been emphasized by the present conference at which some fundamental principles of medical education had been considered. It had been agreed that teachers were privileged not to teach, but to help students to learn the basic principles which must ever underline great medicine.

An endeavour had been made to enunciate these principles and to try inevitab~

to separate them from the vocational aspect which

had to be considered.

It had been agreed in the first session that the fundamental principles were training in exactitude and scientific method tinged all the time with humanism. It must not be forgotten that doctors did not work with patients, but with human beings, not o~

in bed or as outpatients but in the great environment

from which they had come, which included not only the physical but also the social environment, the inter-personal relationships which had to be and students had to be guided in their reading and study. learne~

The stuQy group

had revealed how dependent ultimately they all were on the social and economic milieu of the •••

WPRD/SOC.PREV.MED./Min/7 Page 15

milieu of the countries from which they had come.

No advancement could be made

without the full co-operation of the community and the educational, agricultural and governmental authorities. In other words, it was impossible to differentiate The ideals

aqy one aspect of great medicine from the whole cultural complex.

defined were that in the future, every doctor, whatever be the label on his back, will be fundamental~

a social physician - a health officer within his own field

of influence.

This was a return to the Hippocratical ideal which always included The recent specialization of medicine had resulted

the whole environment of man. • inevitab~

in more or less watertight compartments, and there was a tendency to

forget the individual patient - and that his diagnosis depended on a study of his Social circwnstances. In many countries, this ideal had not been lost. The In

general practitioner of medicine had always been practising great medicine.

the recent period, there had been immense development of specialization and the tendency had been for the doctor to narrow his view to the technology of hiB subject. With the development of social services, every effort must be made to

ensure that doctors know what facilities would help them in their great task so that they would be able to deploy the social forces at their disposal, not necessari~

to do it themselves, but to know where to turn and to be working,

not as a superior person, but as a humble member of what might be called the domestic team which works with the hospital team tJ promote the health of every individual. Sir CHARlES felt that some progress had been made in defining the objectives, realizing as had been stated in the previous sessions, that there were \ \

no utopias and that the idea that there was ,a utopia was which to strive.

on~

an ideal to

In closing •••

•

WPRO/SOC.FREV.MED./Min/7 Page 16 In closing, he thanked Dean LARA and his colleagues for the courtesy they had shown to all participants, the secretariat, the Regional Office and all the workers for eve~

facility that had been provided for the meeting.

Dr. GRZEGORZEWSKI referred to the great value attached to the contacts and links established during the meeting. It was not on~

from the point of

view of international health co-operation but from the point of view of international co-operation altogether that importance was attached to this sort of contact which went beyond boundaries and cultural heritages. WHO did not

consist of the secretariat and government delegations alone, but of all those who were interested in this particular avenue of human progress. In fact,

delegates represented the interest of the health of their nations; so in order to present the views, trends and work done in their countries, they relied on institutions and people such as the participants present, be they in teaching, in services or other forms of work including medical practice.

Coming closer to the educational programme with which this meeting was primarily concerned, Dr. GRZEGORZEWSKI pictured a world where in eve~

country

or group of countries some clear ideas about the preparation of medical personnel would be translated into practical tangible results. One of the ways to

do it was through studies of the needs of countries, including medical manpower, to determine the realistic optimum, both in quantity and quality of medical and related personnel that the countr.1 should need for its healthy development. It had been mentioned that the next step following this discussion should be a study of medical schools or problems of medical education in eve~

country.

As no single country was without a problem in medical education, the methodology of facing these problems, of studying them and trying to cope with them should be a •••

WPRO!SOC.PREV.MED.!Min!7 Page 17 should be a very helpful exercise. The difference should be in the nature

or stage of the problem, but not perhaps in the basic principle of approaching the needs of communities. Gradually an active programme in medicine

might be developed in each country by itself, and in this development cooperation with other programmes would perhaps be valuable. Dr. GRZEGORZEWSKI we~t o~

to say that it had been stimulating to hear

the various views on the s. operation that was manifest

subject and to see the sort of mutual coat such a meeting. He hoped that the meeting

had been useful to those who study the problems of international relationships and to those who feel responsible for national development in each country. He thea referred to the work of the Filipino colleagues in the fields of teaching and service, and to the achievement made under the difficult conditions which their history had placed on them dUring the past several years. In spite

of this they had developed a spirit that was progressive and realistic, combined with humane and medical ideals and this was, he felt sure, characteristic of their total Rpproach to the problems of health and social development. Dr. GAN stated that this was the first time that a study group had been

...

held by WHO in the Region to discuss a specific aspect of medical education•

This

step was, in part, the implementation of a resolution which had been passed

by the Regional Committee for the Western Pacific at its third session held in Saigon in 1952. For reasons already mentioned in the course of the st~

group, it had not been possible for the Organization to have every medical

school in the Region represented at the meeting.

Neither was it the intention

to interfere with the policy and administration of each university and government in the implementation of its system of medical education. The results

of the meeting would, however, be transmitted to each medical school, whether represented at •••

WPRO/SOC.PREV.MED./Min/7 Page 18 represented at the study group or not, and it was hoped that wherever possible, a national conference would be held for the purpose of exchanging opinions on the effective teaching of social and preventive medicine as a fundamental means of increasing the efforts in meeting the health needs of the people. The possi-

bility of having a follow-up study group on the same subject or a related one would be borne in mind. In this connection, the Regional Office would be in a .'

position to render advisory service in the planning and implementation of such national conferences. Some medical schools had periodically been reviewing

their position with respect to the improvement of their undergraduate teaching and others were about to do so. He was sure that the results of the study

group meeting would, in one way or another, help all medical schools in the Region in their efforts to produce graduates who would practice what Sir CHARLES HERCUS had so aptly termed "great medicine" - medicine that embraced all social, preventive, curative, promotive and rehabilitative aspects. Such a concept of

medicine was not by any means new, but the question still remained - are we all teaching great medicine and are all of the graduates practiSing it? Dr. GAN stated that he noted from the draft of the final report of the study group that there had been no serious disagreement between the deans, the pre-clinical and clinical professors and professors of social and preventive medicine. This was proof in itself that all recognized sufficient~

the

importance of social and preventive medicine.

While in one extreme there were

a few schools that were planning to establish such a department, and in the other extreme there were many schools with well-established departments of social and preventive medicine, one could detect in the deliberations of the study group unanimous agreement as to the spirit in which students would learn the concept of ••• I

.1 .1

WPRO!SOC.PREV.MED.!Min/7 Page 19 concept of comprehensive or great medicine. He did not have the least doubt

that medical schools in the Region would play a leading role not only in the improvement of their nations' health but also, in conjunction with the other faculties of their universities, in devising ways and means of improving the socio-economic conditions of the most important element of any socie~

- its

The role that WHO had

pl~ed

toward the success of the study group was generous~

small compared to the time and effort the participants had so buted during the past two weeks.

contri-

Dr. GAN thanked the Philippine Government,

the various institutions in and around Manila and members of the Government and institutions concerned for the kind hospitality and co-operation each had extended to members of the stuqy group. Last but not the least, he thanked

Dr. GRZEGORZEWSKI for the interest and the active part he had taken in the study group meeting. Sir CHARLES HERCUS declared the stuqy group closed at 11:10 a.m.

'IJPRO/SOC.PREV .rOO./Min/7

ANNEX I REl'URNS CF srUDY GROUP GENERAL EVALUATION SHEET

(This is based on the 26 completed sheets received and is a summary of the opinions given.) 1.

In your opinion the objectives of the Study Group were 9 replied comp1ete~

realized

1 replied 1 16 2.

fairly completely realized mostly realized partially realized

replied replied

Do lOU feel that the agenda was satisfactoEY?

17 7 a.

replied replied

yes no

If not, what items not included should have been discussed? (1)

Comparative stuqyof medical schools. Discussion of working papers at the beginning of the meeting.

(2)

• b.

What items on the agenda were discussed too (1)

fu1~?

There was a feeling that there was considerable repetition in the items listed under various topics, particular~

with respect to agenda item ? which was concerned with practice facilities and community research. (2) One thought that agenda item 6 was rather too fully discussed. c.

Which items in the agenda had too little discussion? (1) Research, which some said should have been inclUded as a separate agenda item.

WPRO/SOc.PREV.MED./Min/7 Annex I Page 2 (2) One listed agenda item 2, definitions. particular~

concerning

There was some confusion as to what was

social medicine and what was social and preventive medicine. (3)

Agenda item 3 - particularly with regard to curriculum planning and development, and teaching methods.

(4)

One mentioned agenda item 5 on co-ordination between the departmeut of social and preventive medicine and the other departments of the metical school. One thought that the type of visits students should make might have been disoussed.

(5)

other comments: Several said that the items of the agenda were repetitive and others said that the agenda could have been shortened. Some felt that in many instances the programme was stretched too much. Another said that only the main items should

I J I

have been put down on the agenda leaving the details to be worked out by the groups during the first two days. One

• II II

regretted the cancellation of the special interest group on health education.

.JI

The scope of the Study Group was 21 replied just right too large

4 replied 4.

The total length of the Stugy Group (2 weeks) was 15 9 replied replied i t was too long

I )

it was just right

WPFI.O/SOC.PREV.MED./tUn/? Annex I Page :3 The Stugy Group schedule was :

:3 stated: too crowded ,,0 mentioned 2 said: I

about right

too loose

The Study Group schedule could have been improved bl : a. b.

One said agenda items could have been more flexible. Another suggested that there should have been two free afternoons.

Another that there should have been on-the-spot discussions at the conclusion of each field visit.

That, there should have been greater precision in the agenda items.

Another suggested that the schedule could perhaps have been streamlined during the first two or three days and the last two or three days.

•

Physical arrangements for the Study Group such as hotel accommodation, meeting place, simultaneous interpretation, etc. were : 15 said 8 said 1 said thay were good they were satisfactory they were unsatisfactory

Ppysical a.

arrangements for the Stugy Group could have been improved

Many commented on the poor accoustics of the group discussion and plenary session rooms.

b. c.

Some complained about the hard seats. There were also complaints about the hotel, where there were no facilities for writing in the bedroom, for the members to meet informally and the service at the dining room was slow and

bad.

WPRO/SOC.PREV.MED./Min!7 Annex I Page 4 9. Organization of Study Group Planning Committee was 10 said 9 said 4 said 10. it was good it was satisfacto~

it was unsatisfactory

Organization of the discussion groups was 13 said 10 said 2 said it was good satisfacto~

unsatisfactory

11.

The organization of the p1ena!y sessions was 8 said 14 said 3 said it was good satisfactory unsatisfactory

12.

The conduct of group sessions was 13 said 9 said 2 said it was good

satisfactory unsatisfactory sessions was

13.

The conduct of

p~enarY

9 said: 13 said

it was good satisfactory unsatisfactory

3 said 14.

The conduct of the field visits was 16 said (, said 1 said it was good satisfactory (one of whom mentioned that there should have been more field visits) unsatisfacto~

...

WPRO/SOC.PREV.MED./Min/7 Annex I Page 5

15. Working hours for the Stuqy Group were 20 said

about right they were too long

5 said

16. Library and reference facilities were 15 replied 4 replied

they were adequate barely adequate inadequate

3 replied

17.

On the

whole~

this Stu9l GrauE has been to me of considerable value of some value

20 said 5 said 18.

Please indicate any frank criticisms and suggestions for this Study GrouE which will aid in the Elanning and operation of future meetings of this nature a. A few mentioned that there was a domination of the discussion by some members. Another thought that this domination was Others said that this domination

unforuunate but unavoidable.

.. b.

improved later on • Appreciation was expressed to Dr. secretariat. L~ra,

the WHO staff and the

Appreciation was expressed to the secretariat for ~riticisms

their action in attempting to remedy the

expressed

in the evaluation that followed the conclusion of each agenda item. c. One commented that the interpreter was excellent.

Another mentioned that the field trips were well organized and prepared but suggested that 'examples of teaching and demonstration of such examples might have been given and that some time might have been allotted for recapitulation after each field visit.

, , • 1,..:.

WPRO/SOC.PBEV.MED./Min!7 Annex I Page 6 d.

Several participants looked forward to another similar stuqy group meeting two or three years later.

One participant criticised that the entire scope of the meeting was too diffused am that there was confusion as to social and preventive medicine. medicine and othe~of

He felt that some were talking of social preventive medicine. He believed that the

two should have been taken separately and not considered together. f.

Another asserted that the meeting was successful and he appreciated the invitation of the triad of medical school dean, professor of social and preventive medicine and clinical professor and suggested that this pattern be followed in similar meetings in future.

Another participant thought that. there might perhaps have been more entertainment in the evening.

One participant mentioned that more information might have been given with respect to taxi drivers.

i. j.

One gave emphatic approval of the length of the meeting. Another suggested that ref~rences

should have been cited and that

appropriate working papers mentioned in the respective agenda items. k.

Another suggested that the groups should have been oriented as to group work.

Another made the observatibn that all books in the library except one were American and hoped that this position would be rectified.

m. n.

Another expressed appreciation of the special interest groups. One who expressed that he was looking forward to a similar meeting in the future suggested the inclusion of visits to teaching activities in various countries in the Region. he had learned a gooddlal at the meeting. He coniluded by s~ing

that .~

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Technical Documents

Дата принятия 31 декабря 1957 г.

Источник Всемирная организация здравоохранения