One of the topics that continues to cause debate among healthcare professionals in developing countries is the comparative value of clinical versus public health careers. There is a tendency to rate one over another. Some claims state that clinical practice is the heart of healthcare because doctors deal directly with sick people, who are the real people in need of healthcare services, and the reason why more investments in this field are critical. On the other side, public health aficionados argue that public health deals with enormous preventive community health challenges, invoking the idea that ‘prevention is better than a cure’.
After I graduated in general medicine in January 2012, I worked as a general practitioner at some district hospitals in Rwanda. I was very motivated and excited to begin my career in clinical practice. At the hospital, general practitioners were consistently overwhelmed by the workload, while the phrase “shortage of staff” was repeatedly brought up during staff meetings. Moreover, high levels of personnel turnover led to frequent welcomes to new comers and goodbyes to outgoing ones, which led to a hospital manpower deficit and inadequate follow up for patients.
One evening as I was on a night duty, I received an emergency phone call from a remote health center where there was a mother with a complicated labor that needed a level of care only available at a hospital. I ordered the ambulance to go there and bring the patient as soon as possible. I had understood the case and knew that all materials and drugs were available to help the patient, and I awaited the patient until early morning when I called back the ambulance to check if the patient had arrived. Apparently, the ambulance had struggled with terrible road conditions, and when it reached the health center the newborn had passed away and the ambulance staff had decided it was too late and there was no need to bring the mother to the hospital.
Over time, I have come to realize that having health facilities, and even having trained and available clinicians, is not enough. Those things cannot adequately improve health outcomes unless the health systems level issues of access are addressed. There must be appropriate means by which a patient can reach and receive appropriate healthcare at the right time and place.
A few months later, I did an interview. It was for my application for the Global Health Corps Fellowship, and one of the interviewers asked me, “Why do you want to stop clinical practice?” I responded that I wanted to be a health worker on the frontlines, and to contribute to efforts to create systems in which patients can reach health facilities and resources when and where they need them.
Early on in my fellowship year, one of my priorities was to train selected volunteers who provide health education, basic preventive health care and home visiting services in their villages, so-called community health workers. We trained them on issues relating to RapidSMS (a mobile phone-based technology to improve maternal newborn and child health in Rwanda) and to prepare and submit weekly reports about the incoming data. I had opportunities to go to remote villages, meet community health workers, and face real health problems at village level. Through these contacts, I have learnt that preventative health is not only a matter of a pathological process, drugs or interventions to cure diseases, but also social, economic, environmental, and political approaches towards the wellbeing of communities. This exposure has helped me see that the complexities of health problems in the developing world require multi-sectorial approaches including both clinical and public health fields, not one or another alone.
Therefore, I now feel that I have a better answer to the question about the comparative worth of a clinical or public health career. The most worthy and impactful approach to improving health is neither a clinical nor a public health path apart, but a combination of both. The study and practice of clinical vocations without consideration of public health progress is partial, and vice versa. A connection of strong clinical and public health works is crucial for an effective health equity movement, and I feel my contribution to this movement will be amplified thanks to my opportunity to observe the intersection of clinical programs and public health methods via the Global Health Corps Fellowship.