Merge, morph or marry: Integrating social sciences and medicine

An identity crisis grips the community medicine fraternity in India. We are permanently in debate with our subject. Is our subject medical or social? Is epidemiology our core discipline or the social sciences? Are public health and community medicine the same? And so on.¹ The ‘discipline’ itself transcends all the above labels and resists categorization as a single homogenous identity. While I may be comfortable in my skin at my age in a largely non-clinical role with strengths in epidemiology and the health system, this does not help individuals or young professionals grappling with this identity crisis. How do we resolve this identity crisis?

Shorn of any adornment, public health or community medicine is shifting a community from its current place to a healthier place. For this, the community is the prime internal mover with nudge and push from the health system as an external force. Epidemiology is concerned with measuring correctly and identifying the effectiveness of interventions, while social sciences teach us how to collaborate effectively with communities. That is why these are considered core to the discipline of community medicine or public health.

Public health professionals can come from either a medical background (medicine, dentistry, nursing) or the social sciences (anthropology, economics, political science). Medically trained people do not have adequate knowledge and understanding of social aspects, which hamper community-level work. People in the social sciences feel less respected due to a lack of knowledge of medicine, and it also puts them at a disadvantage in some respects, as their understanding of medical aspects is not adequate.

Thinking about this identity crisis reminds me of another— the gender identity crisis. Gender identity disorder (GID) is a conflict between a person’s physical or biological gender and the gender that person identifies himself or herself as.² We use the term ‘sex’ in a biological context and ‘gender’ in a social context, recognizing that these are not necessarily the same. Also, today we consider gender differences as differences in degree (treating it as a continuous variable) and not as an absolute (categorical variable). We no longer think that biology necessarily defines the identity of a person. Freud believed that all humans, because of their bisexual disposition and cross-inheritance, combine in themselves both masculine and feminine characteristics. It is what you believe about yourself that defines you.

I propose that medical/epidemiological/quantitative approaches are akin to the ‘masculine’ aspect, while a social, non-clinical, qualitative aspect is the ‘feminine’ aspect of the discipline. Epidemiology is about hard facts and numbers, whereas social sciences are all about softer aspects of perceptions and beliefs. Akin to people with GID, we are torn between the social and medical aspects.

The ‘nature versus nurture’ debate is about whether genetics (nature or the hardware) plays a bigger role in determining a person’s characteristics than lived experience and environmental factors (nurture or the software). It is impossible to know precisely where the influence of genes ends, and the environment begins or vice versa. As above, looking at nature versus nurture in black-and-white terms is considered a misguided dichotomy, as there are many shades of grey where nature and nurture overlap. Epigenetics blurs the line between nature and nurture because it says that even after birth, our genetic material is not set in stone; environmental factors can modify genes during one’s lifetime. Epigenetic mechanisms alter DNA’s physical structure in utero (in the womb) and across the human lifespan.³ Today, we are veering towards the view that ‘nature with nurture’ as opposed to ‘nature versus nurture’ is the most important influencing factor.

In a patriarchal or traditional society, the male viewpoint is often presented as the ‘default’ perspective, and this is seen as ‘normal’. In the context of this paper, this is akin to a medicalized model being accepted as the default perspective in departments of community medicine, with social sciences being treated as the ‘other’ perspective. In cinema, the female gaze has been used to refer to the perspective a female filmmaker (screenwriter/director/producer) brings to a film that is likely to be different from a male view (traditional) of the subject, both in the forms of stories selected and the treatment meted out. A female gaze is emotional and intimate, provides an insight into the lived female experience, and seeks to empathize rather than to objectify.⁴ Both cinemas are relevant and equally important. They are not mutually exclusive.

Based on these examples, I point out that both medical and social sciences are inherently central to public health, and we need to find ways of integrating these. Building on the gender example and borrowing from Indian mythology, I postulate three ways to combine masculine and feminine essence in the strongest way and not treat it as a dichotomy—The ‘Ardhanareeshwara’ or merge model, the ‘Mohini’ or morph model, and the ‘Vivah’ marriage model.

In the ‘Ardhanâriúvara’ or merge model, Shakti, the female principle of God, is inseparable from Lord Shiva, the male principle of God. Purusha, the male principle, is a passive force of the universe (health system), while Prakriti is the female active force (community).^5,6 In simpler words, this makes the case for each public health professional to be well-trained in both the medical and social aspects of public health.

In the ‘Mohini’ model, Lord Vishnu (masculine) morphed into Mohini (feminine version) on occasions where it was required, especially to kill the demons. In the same way, if defeating diseases requires medically trained people to don a ‘social sciences’ avatar and vice versa, they should be ready for it.

In the ‘marry’ model, as we all know, the man and woman come together, share appropriate responsibilities, and work together for individual, family, and societal progress. This would mean that social and medically trained people learn to work together with equal respect for each other. Without that, marriages will not work, nor will public health be able to deliver effective services.

If epidemiology is the ‘eye’, the social sciences are the ‘ear’. There is no question of granting primacy to either of them. In pursuance of this interdisciplinarity, we either learn to work together or become equally adept at medicine as well as the social sciences. So, rather than emphasising and belabouring the differences between the medical and social aspects in public health, I propose that we join hands to become a strong, constructive force that improves the health of the people. Pooling the strengths of the social sciences and epidemiology produces true public health/community medicine.

For all the young community medicine or public health professionals, my message is that it does not matter where you come from; ensure that you respect the interdisciplinary nature of the discipline, be comfortable in your current position in the continuum, and evolve continuously.