Community Health in the Curriculum

The Autumn 2020 issue of Harvard Medicine includes a letter from Henry Kahn, MD ’68, relaying his appreciation of the 2020 Class Day comments by Robert Satcher Jr., MD ’94. In his address, Satcher reminded his audience of the “underlying deficiencies of our society” and the “collective denials rooted in historical and institutionalized injustices.”

Satcher’s message prompted Kahn to reflect on his Class Day presentation 52 years earlier.

 

Over the past several years American medicine and this medical school have come to recognize an increasing scale of social responsibility. We have seen the acceptance of "community health" as a legitimate concern and even as a specialty interest for modern physicians. In pursuit of this interest, a number of sophisticated doctors have acquired proficiency in such skills as budgetary economics, sociological analysis, demography, cybernetics, administrative law, communications, and motivational propaganda. The new curriculum will undoubtedly enable certain students to develop these techniques while still in medical school, just as other students will delve deeply into isotope medicine, hemodialysis, or electron microscopy.

So it should be. After all, our future practice and research will follow many different paths and so should our education. Medicine has effectively adapted the techniques of physics and chemistry, and it is now adapting those of social science. Our preventive medicine and elective course options even now suggest this direction. I have no doubt it will develop rapidly. Physicians and their educational institutions are very resourceful when it comes to appropriating the technical developments of other disciplines.

However, all this reflects the trade-school aspect of medical education—a function we should readily acknowledge, but not the aspect on which I would like to focus today. There is another side to community health activities which has not found a place in the medical school curriculum, nor is it represented in the School of Public Health. I am thinking of the educational experience that transmits not necessarily a technique but a set of values. I should like to consider that part of the doctor’s training that results not so much in a skill, but in a firmer and fairer commitment to those large groups in society that we have ignored or patronized for so long. This is the aspect of medical education for community health that demands our attention today in these times of increasing professional narrowing, isolation and alienation.

In Mississippi

As I attempt to plan my future as a physician and citizen, I frequently think of several personal experiences in community health activities over the past four years.

I think back, for example, to 1964, the summer immediately before I entered medical school, when I spent a week in North Central Mississippi as assistant to a health team sent by the Medical Committee for Human Rights.* The South was not new territory for me. I had traveled in that part of the country many times before. Five years earlier, I had attended a National Science Foundation high school summer session at Mississippi Southern College in Hattiesburg, and five years before that I lived for a year in a small city in Florida where I was enrolled in the local central school. However, this one-week visit to Mississippi during "Freedom Summer ’64" offered a different sort of education. Our team's assignment was to provide medical presence and services for civil rights workers in five counties. We arrived one week after the discovery of the mutilated bodies of Chaney, Goodman, and Schwerner.

Characteristically, the young civil rights workers insisted they themselves needed no medical attention, but urged us to devote our efforts instead to the health problems of the local citizens whom the movement had come to serve. We took their cue, somewhat embarrassed not to have thought of it first and hardly knowing where to begin. The one practicing Black physician in the region, presumably out of fear, chose not to speak with us. White physicians also generally refused, and even the one notable exception advised us to mind our own business and insisted that we not tell any of his colleagues that we had spoken with him. The young, Black dentist in the area spoke to us with great suspicion, unable or unwilling to talk about the nature of his patient load, dental hygiene in the community, or his relations with local, white practitioners.

By contrast, the excellently-trained, local health officer was talkative and cordial to an extreme, although his sense of euphoria was slightly alarming. He assured us that all local health problems were under control and adequately reported. The large stocks of contraceptive pills which he distributed at cost would, in any case, rapidly improve the health and welfare of the Negro citizens. He regretted, however, that "outside agitators of extremely radical political persuasions" were destroying local customs, forcing Negroes to abandon their “delightfully oriental traits” of respect and responsibility. "With all this agitation," he lamented, "the Negroes are losing their values and beginning to count on the State for the welfare of their elderly and indigent, just as whites have always done."

The local Black leaders and the civil rights workers cared passionately about the community around them, they identified with its broad social and political interests, and they were trusted. Doubtless, these laymen had the most to teach us about community health.

We gained essentially no information from the administrators of two, small, county-supported hospitals in the region. One of them volunteered nothing during our brief conversation except a frequently repeated reminder that his institution was built entirely with local funds, that is, without Federal Hill-Burton money (thus, outside the pale of any Federal Civil Rights provisions). The administrator of the more modern of the two hospitals quizzed us intently about our faith in God and knowledge of New Testament scripture. Fortunately, our team leader was a devout and well-read Protestant missionary physician, but even that may not have satisfied him. As we drove out of the hospital parking lot we were followed by an unmarked car which tailed us out into the open country where it then pulled up alongside our automobile and forced us off the highway. Two non-uniformed, middle-aged men stepped out, claiming to be the County Sheriff and his Deputy, and took notes on all our identification papers. They warned us that many important people in the County wanted us to keep out and would do us physical harm if we stayed in the area. If we were not learning about community health, at least we were beginning to learn some lessons in community sickness.

It quickly became evident that the local professional community was not necessarily best equipped to describe or understand the health issues in the surrounding population. In this Mississippi context, the lay Black leaders and the civil rights workers had much more relevant information, and they could quickly fill gaps in their knowledge. They noticed which families were excessively thin and which were overweight; which had clean running water and which had only outhouse privies. They knew in which hospitals and under what circumstances a Black patient might be refused admission. They knew which families forbade smoking and which forbade birth control. They had a reasonable idea of who was diseased, whose baby had died, and who was not immunized. The local Black leaders and the civil rights workers cared passionately about the community around them, they identified with its broad social and political interests, and they were trusted. Doubtless, these laymen had the most to teach us about community health.

In Massachusetts

But a Mississippi experience should not have to stand alone in illustration of more general points. I should mention an experience in the summer of 1965, after I had completed the first year of medical school and wanted to learn something about health problems here in the North, in this case, Roxbury, Massachusetts. With the support of Harvard's Laboratory of Community Psychiatry, two other students and I attempted to find out how some of the Roxbury citizens viewed local health facilities and how their perceptions influenced their utilization of these services. The Boston Chapter of the Medical Committee for Human Rights, concerned with Northern problems as well as those in Mississippi, had established a reservoir of good will in Roxbury by providing free summer-camp physical examinations for over 400 local children. By being identified with these, we found it relatively easy to ask the parents of these children about their health care. I myself interviewed 26 families in considerable depth, most of whom were Negro, poorly educated, and in what we consider the poverty class. They had a lot to tell us.

I asked the primary respondent in each of the families, for example, "If you had a chance to set up and manage all the health services in Boston—no worry about cost—what kinds of changes or improvements would you make?" Some were initially reluctant to respond, but with a little encouragement each gave thoughtful answers. As one might imagine, many responses included suggestions about the City Hospital such as reducing the waiting time, enlarging the staff, and modernizing the facilities. But the expression of responsible concern and imagination went far deeper: "Send more local children to school to become nurses and doctors"; "Clear out the storm sewers to prevent big lakes in our streets after rains and clear the trash out of the vacant lots"; "Poor people should have evening clinics at City Hospital"; "The government should sponsor regular exterminations of pests in both public and private housing." Perhaps no professional before or since has asked these Roxbury citizens what they thought about their medical care or what they would do about it. But I maintain that only through exchanges of this sort can we intimately understand the community and its health issues.

I have become convinced that the successful understanding and practice of community health requires a physician who can pledge primary allegiance to the social and political aspirations of the community he serves.

This process of identification with community concerns need not and should not, however, be limited to the relatively cold and passive interview technique. Just last month, for example, the Medical Committee for Human Rights set up a temporary first-aid station in Boston's South End at the request of Community Action for a United South End (CAUSE). We were there to support the squatters in Tent City who had occupied a commercial parking lot for three days of dramatic and imaginative protest against the short-sighted policies of the Boston Redevelopment Authority. It was a great privilege and certainly very educational to be even a peripheral part of this warm community—Blacks, whites and Latinos working together effectively toward common goals. There were essentially no problems of poor patient motivation or professional alienation. Because we accepted and identified with the aims of Tent City, its members accepted us and sought our services whenever necessary. We learned about the community from the militant Black adolescent who cut himself on a rusty nail and would not go to City Hospital. We learned about motivation from the down-and-out South End alcoholic who found himself swept up in the creative spirit of Tent City, stopped drinking for 72 hours, and then began to slip into delirium tremens. These are important lessons in community health.

I have become convinced that the successful understanding and practice of community health requires a physician who can pledge primary allegiance to the social and political aspirations of the community he serves. We may call him a professional out of respect for his skills, but he must distinguish himself from his professional predecessors by learning and embracing the democratic values of the social movements around him. He must willingly accept as his teachers the poor, the disenfranchised, the revolutionary students, Blacks, Indians, and all those others whom he might have treated in the past but rarely considered as his equals. In essence, the community health physician has to learn a new ideology of egalitarian community involvement replacing the old notions of aloof, benevolent professionalism.

I should not wish to criticize any educational institution unfairly for reflecting archaic patterns which still permeate our society as a whole. It should be recognized, however, that medical schools continue to impart the traditional ideology of paternalistic professionalism without any real prospect of change. Our faculty here, for example, is 99 per cent white and 100 per cent middle or upper class. This fact by itself teaches the ancient ideology and conflicts with the modern lessons of community health. On the other hand, I consider it significant that my most treasured educational experiences in the community health field occurred under the tutelage of Mississippi sharecroppers and radical community organizers, entirely apart from the medical school curriculum. I strongly doubt that this institution as currently structured and supported can ever, on its own, impart the ideology of egalitarian community involvement.

But it must be learned. Perhaps the best that the medical school can do at this point in history is to encourage interested students to develop their own close contacts with social and political movements in the surrounding society. Where the medical school itself will fail, new groups like the Student Health Organizations and the Medical Committee for Human Rights may succeed in guiding students across the chasm which now separates the conventional professional from the vital community. Without this venture there can be little significant progress in education for community health.

Henry Kahn, MD ’68, is a professor emeritus at Emory University. This transcription of his address, "Community Health Activities in the Curriculum," appeared in the Harvard Medical Alumni Bulletin 42, no. 5 (1968): 26-28. A limited number of changes have been made to the address to conform to current editorial style.

* The Medical Committee for Human Rights was dissolved in 1980. A history of the organization appeared in the September 2014 issue of the AMA Journal of Ethics.