Photo: Annie Spratt / Unsplash

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• A review of five subjects in the undergraduate medical curriculum found that they do poorly in integrating the social determinants of health.
• Perhaps the most notable absence concerns issues relating to violence against women, as domestic violence is now recognized as a public health problem.

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In August 2019, when the Medical Council of India (MCI) introduced the “Competency Based Medical Curriculum”, medical education in India underwent a radical change. The MBBS program was under review after 21 years.

The development process was based on a vision document called “Vision 2012”, for the undergraduate program. It was developed by a distinguished committee of senior teachers in 2011, during the term of MCI’s first board of directors. Later, a “Vision 2015” document was released with minor changes, but was not implemented.

The 2017 National Health Policy drew attention to gender inequalities and included a comprehensive response to gender-based violence as one of its priority areas. The policy has also placed emphasis on mainstreaming a gender perspective in the undergraduate curriculum of medical students, in order to reduce inequalities in health care.

There were several expectations of the new MBBS program due to the time it took to revise it. We expected these reviews to focus on the often overlooked social determinants of health. A competency-based medical education program focuses on building the skills of medical students to become competent and qualified – and develop an empathetic and responsive attitude towards the patient community.

This would require a framework rooted in an understanding of intersectional issues of gender, caste, religion, disability and gender identity, and adequately addressing the inequalities that different marginalized communities already face.

Where are the social determinants of health?

We have selected five subjects / disciplines to conduct an in-depth curriculum review, as they offer the opportunity to integrate the social determinants of health. These included community medicine, internal medicine, gynecology and obstetrics, forensics and psychiatry.

The review of these disciplines left much to be desired when it comes to a transformational approach to medical gender education.

Community medicine is a core subject in undergraduate education because it lays the foundation for understanding the concerns of communities. We found only one conference, “Gender Issues and Women’s Empowerment”, in the 5.5 years of the community medicine program.

While this can be seen as a step forward, a single lecture will not help students understand gender issues nor give them the space and time to navigate the complex links between gender and empowerment. women.

We also did not find any references to taking into account the health problems of people with fluid sex. In the absence of these basic concepts at the foundational stage of an MBBS, we have lost an opportunity to broaden each student’s worldview on gender issues.

A review of the Forensic Science and Toxicology program indicated that it still includes non-scientific terms such as “defloration”, “virginity test”, hymen types, and so on. There is sufficient evidence to indicate that these terms have no basis in medical science. On the contrary, they perpetuate prejudices against women.

The Ministry of Health and Family Welfare, in its 2014 guidelines for the forensic examination and care of victims of sexual violence, clearly calls for the exclusion of these terms as well as the removal of harmful medical practices such as virginity testing, evaluation of the addiction to sexual activity, determining the victim’s sexual history, assessing a survivor’s resistance based on her physical makeup, among others.

If these terms are not removed, learners and teachers alike will fall back on archaic, court-banned medical practices as well as medical science.

A perspective on the issue of violence against women is conspicuous by its absence in the undergraduate curriculum. This is despite the fact that domestic violence has long been recognized as a public health problem. Although there is growing global and Indian evidence on the prevalence of violence in pregnancy, the Obstetrics and Gynecology program is silent on this issue. Indeed, the skills listed for gynecology and obstetrics have no way of assessing students’ sensitivity to violence suffered by pregnant women.

Even though several programs in India focus on improving maternal and child health, domestic violence or intimate partner violence, which are huge risk factors for women’s health, remain unattended by doctors – much of which is linked to the lack of training of medical personnel on the relationship between domestic violence and the resulting health impact.

A glaring gap relating to the “suicide attempt” is noted in the program relating to medicine as well as psychiatry. While the discipline of medicine has a series of lectures dedicated to teaching biomedical care for patients reporting organophosphate poisoning, it does not mention that these patients may have attempted suicide. The skills related to this topic should have presented guidelines to allow students to research patient histories to find out if such poisoning was accidental or if it was a suicide attempt.

There is growing evidence from public hospitals across India that “accidental poisoning” is a key sign of attempted suicide due to underlying stressors, including domestic violence.

Likewise, the subject of psychiatry is concerned with the question of suicides and the understanding of the factors underlying such attempts. It was possible to conduct a sensitive survey of suicides and assess whether they were related to domestic and / or sexual violence. But the program is silent on these aspects.

On the one hand, the CBME program emphasizes the importance of recognizing and teaching “the areas of attitude and communication with an emphasis on ethics; but the gaps mentioned in our review indicate several inadequacies in the effective consideration of the social determinants of health. Unless these gaps are addressed, the creation of gender-sensitive physicians with specific skills tailored to the medical needs of the community will remain on paper.

The path to follow

Although CBME is an important step forward from the previous MBBS program, it falls far short of truly mainstreaming gender and other SDH concerns into undergraduate education. CBME’s preamble seeks to create a patient-centered physician, who develops gender sensitivity and compassion for patients – however, this is not reflected in the content of core disciplines.

We would like to draw attention to the efforts of the Maharashtra University of Health Sciences (MUHS) towards gender mainstreaming and gender awareness – by creating gender integrated modules in the MBBS curriculum existing, in 2018. Gender content was integrated into five disciplines of the undergraduate program based on five themes

1. The social construction of gender – which helps pupils to understand the social construction of gender, how gender functions as a system and defines the roles of men and women according to the expectations of society and grants a secondary status to women. Content based on this theme also focuses on transgender identities and alternative sexual orientation.

2. Gender as a social determinant of health – which includes lessons on the gendered nature of health problems, gender biases in diagnosis, stigma and other consequences of certain diseases on women, gender issues in current health programs and policies and differences gender in access to resources and health care.

3. Gender-based violence – content based on this theme includes definitions of the different types of violence, the prevalence of different types of gender-based violence and their links to health, the role of health providers in responding to gender-based violence, the various laws, guidelines / protocols and their mandate for physicians and health facilities.

4. Abortion, contraception and sex selection – which emphasizes a nuanced understanding of the laws on medical termination of pregnancy and on the prevention of the misuse of preconception and prenatal diagnostic techniques (PCPNDT), and specifying that the PCPNDT law does not restrict access to abortion. Several questions regarding abortion and contraception are included.

5. Ethical issues in practice – which focuses on ethical issues in practice, including the concepts of informed consent / refusal, privacy and confidentiality, recognition of patient rights and gender sensitivity in history and examination.

These modules complement undergraduate education as they provide medical educators with evidence and participatory methods to mainstream gender concerns. A total of 81 gender integrated lectures across five disciplines – Obstetrics and Gynecology, Community Medicine, Internal Medicine, Forensics and Toxicology, and Psychiatry – were developed and taught over the 5.5 years of the MBBS program.

Modules have been reviewed by MUHS Academic Board and issued to all medical schools in Maharashtra since 2018. These modules are evidence-based as they have been tested through research and indicated high feasibility of their teaching as part of the MBBS course.

In conclusion, an Indian medical graduate can only be relevant locally and globally when she is able to look beyond the biomedical realm of knowledge and skills – and develop a lens that considers the social determinants of health. as an integral part of the provision of care.