A medical educator did, as far back as 1965, pose a question that is very pertinent even today: ‘Should medicine repair damaged health or try to change the social environmental circumstances that led to ill-health?’. The challenge is still before medical educators. Changing the social circumstances requires working on the front-line in rural or poor urban areas. So far medical schools have not been heroes of social medicine although there are projects here and there that are successful and are laudable. In order for medical schools to face the challenge they will have to train medical students in such a way that they internalize the values of social service.

The paradigm of service requires that the physician should be trained to understand medicine as a social service. The human dimension should dominate over the biomedical one. The selection of medical students, their training, and evaluation should emphasize human service and not material gain for the physician. The medical school can not be expected to effectively teach the spirit of serving others. The values and attitudes of self-less service for others are taught by the family and the community and are already well set by the time the student enters medical school. The school can only build on and enhance basic values that students bring with them from their homes and communities. In such circumstances, the medical school will do well to select those students who already have the vocation to serve. A medical education or health care delivery system developed within an Islamic society will have no alternative but to be service-oriented. This is because of the emphasis on mutual social support.

2.0 ALLEVIATION OF POVERTY:

Material deprivation causes social and psychological stress in addition to the physical impact of inadequate nutrition, housing and sanitation. Socially conscious physicians must be involved in programs to eradicate poverty and assure a reasonable standard of living. We rae celled upon to look after the weak and the less privileged: the widows, the poor, and the wayfarer. We must love for others what we love for ourselves. The concept of charity includes all good things and not just giving money. Social services must have the ability to seek out those in need even if they do not come to them seeking aid.

3.0 COMMUNITY-BASED EDUCATION: FOR THE MATERIALLY DEPRIVED

There is an increasing emphasis on community and preventive medicine in many medical schools as an introduction to service in less privileged areas. Traditionally, the service vocation in medicine called for training the student to serve in a poor or rural area or slums of the big cities. Involvement of the student in community-based education should be real and not cosmetic or sensational if it will have a major impact on him. The student must actually deliver useful service and should live among the poor for a reasonable amount of time as a fully-fledged professional. The normal prototype of community-based education is setting up a project in a defined community. The vision of such efforts was to break the traditional mould of the medical school as an ivory tower with no community responsibility and no outreach to the socially deprived groups. It was also expected that social responsibility will be taught to students. Such community facilities sometimes actually deliver services or are just an appendage on on-going services. Sometimes the educational may not agree with service priorities. Medical schools have not been very successful in inculcating the spirit of self-less service in depressed rural or urban areas. Physicians are reluctant to serve in rural areas.

Community-based education has three specific objectives: understanding lifestyles, health behaviors, and health beliefs; knowing morbidity and mortality patterns by direct experience; and acquiring problem-solving skills. Community-based education is thought to help the student address social needs and responsibility to society.  It is argued that community-based learning will make the student more sensitive to society’s problems. This makes sense since the majority of those who manage to make to medical schools are often from middle-class urban homes and have no contact with the less privileged who live in rural areas or the urban slums. While these approaches are in the right direction, they have a misplaced conceptual basis. Community tends to mean the less privileged and the poor. It is a palliative approach for a student, normally of middle-class urban background, to ‘feel’ the problems of the poor. A few weeks spent in such communities are not enough to change attitudes held by the student’s social class let alone sensitivity. We need evidence that such brief exposure changes the fundamental outlook like producing a zeal in him or her to leave the comforts of an urban middle-class life for serving in rural areas or the urban slums. It is possible that a short period of working in a less privileged environment only enhances the image the students have that community medicine is second class medicine for the less privileged members of society.

4.0 COMMUNITY-BASED EDUCATION FOR THE MATERIALLY WELL-OFF

The disease profile and hence the pattern of medical care in Brunei is changing with the rapid socio-economic development. The old diseases of poverty (parasitic infections, under-nutrition, poor sanitation) are disappearing. New diseases due to an unhealthy lifestyle of the now richer population are appearing. Over-nutrition, lack of exercise, substance abuse, stress, and psychiatric morbidity are on the increase. The old social and psychological safety nets provided by the family are disappearing leaving many people lonely and vulnerable. Medical students of today will have to be trained to deal with the new patterns of morbidity. Medical schools will have to set up education projects in wealthy communities of urban areas that were not traditionally involved in community-based programs.

5.0 PRIMARY HEALTH CARE:

Medicine is passing through a period of innovative approaches to health care delivery. One of the most recent of these is the concept of primary health care (PHC) that essentially refers to the first point of contact of a patient with the health care system. PHC can be simple in a rural area or quite sophisticated. It does not have the connotation of second-class medicine. The PHC strategy requires training a physicians who will be able to do the following: respond to health needs and expressed demands of the community; work with the community so as to stimulate healthy life style and self-care; educate the community as well as the co-workers; solve, and stimulate the resolve, of both individual and community health problems; orient their own as well as community efforts to health promotion and to the prevention of diseases, unnecessary sufferings, disability and death; work in, and with, health teams, and if necessary provide leadership to such teams; continue learning lifelong so as to keep their competence up-to-date and even improve it as much as possible. We can envisage medical education in the future taking place in primary care settings in both its simple and sophisticated modes.