Worlds away from the laboratory, lecture hall, and academic health center, Wayne State University medical students are helping define a new dimension in medicine: community health.

For much of the 20th century, practitioners of public and private health have followed separate, though parallel paths, evaluating the health of the individual and the community. Physicians learned to treat illnesses and injuries that afflicted their patients. Public health officials examined the big picture of epidemics and general health trends.

Ne'er the twain shall meet. Until now.

The two disciplines have found common ground on the east side of Detroit where medical students are exploring diverse multicultural issues affecting women and young people. 

Shalini Chandra was analyzing data for Wayne State University's Center for Health Care Effectiveness Research and serving on a planning group for the Detroit Medical Center's (DMC) Center for Urban Health, two years ago. She and other members of the group were challenged to "adopt" one of the DMC's ambulatory health centers, located in low income areas of Detroit. Chandra, who was completing her first year at the School of Medicine, eagerly accepted the challenge to experience the other side of her statistics.

Curi Kim, Shalini Chandra and Deborah Czarski (from left) each direct a different component of Students for Healthy Communities.

She addressed the school's Student Senate, asking the elected body to support an outreach initiative among Muslim Bangladeshi women. When Renuka Tyagi, a senator, heard Chandra's appeal, she suggested that the two form a student organization. Together, they created Students for Healthy Communities. That summer, the students submitted a grant proposal to the Cooperative Actions for Health Program, a partnership of the American Medical Association (AMA) and the American Public Health Association (APHA). The initiative's goals are to promote joint strategic planning and stimulate collaborative efforts at the national, state and local levels to produce innovative solutions for public health problems. Students for Healthy Communities was the only student organization to be awarded a grant.

Within two years, the organization won another grant, organized a health information program for the Muslim Bangladeshi women and a multicultural career modeling program involving 25 Wayne State students, and presented to three national and state meetings. The American Public Health Association accepted a poster presentation from the organization for its 1999 conference.

The initial project, funded through the AMA/APHA collaboration, involved community group discussions, organized and facilitated by students, to discuss the health needs of nine ethnic groups who live in the neighborhoods served by the DMC's East Davison Health Center.

"They were our first community outreach workers," explains Herbert Smitherman, MD, director of the DMC's Center for Urban Health and faculty advisor to the Students for Healthy Communities. The DMC acquired a network of urban Detroit health centers from the Michigan Health Care Corporation and needed to establish relationships with the current patients and the communities that the health centers served. The DMC center initially lacked outreach staff and students expressed an interest in being involved with urban medicine, according to Dr. Smitherman.

"Although all of the health centers have been, or are being renovated as state-of-the-art centers, originally and at the time the students were interested in being a part of our outreach efforts, the centers were in significant disrepair," he recalls. His concern was that the poor appearance of the health centers might discourage the young students from long term careers in urban settings. 

"These were people who were very excited about practicing in an urban setting. We didn't want this experience, in any way, to be a turn-off." However, he decided to move forward. "This was what is there. This is the state of urban practice in many cities."

As he worked with Chandra and the other students, Dr. Smitherman was careful to ensure that the experience involve work and education. "I didn't want them to go out without a curriculum," he says. Students met with Dr. Smitherman individually to discuss their personal objectives. "They really wanted to help people. They wanted to meet the community at the community level and really help them."

The students worked and learned a lot, including the limits that they, as providers, had. "We're not going out to be missionaries. We're not Moses. But we provide support so communities can do for themselves," according to Dr. Smitherman.

"How can you appropriately care for a community unless you know what their issues are?" he asks. In the case of the East Davison Health Center, Muslim women were limited in their access to health education by custom and culture in which women are not educated. Initially, the students wanted to create an educational program for these women. But Dr. Smitherman advised against the program being directed by the students, rather than the community.

"How do you negotiate this?" he asks. "You work with the community leadership. Their leadership should develop and own the educational program."

Urban health is influenced considerably by behavior and environmental conditions - social, economic, and religious. "All of these things lead to health," Dr. Smitherman says. "The medical model alone is inadequate. Health is more than the provision of medical services. You cannot stop youth violence through the medical model alone." Yet, urban practices are filled with patients who present the after-effects of violent injury.

"The students are learning that at the ground level, by helping to facilitate and negotiate; empowering people to change their health status. You can't motivate a person. People motivate themselves. You provide the support.

"This is not something you get through a stethoscope. What the students are learning is the art of medicine. The mechanics of medicine is learned in the medical school." Learning how to interpret blood gases is important, but so is learning to negotiate health behavior with patients, he says. "Physicians find out 20 years later that that is the most important part of medicine. It should be integrated as part of the curriculum for all students."

Students have instituted health outreach programs for Muslim Bangladeshi women and other ethnic groups.

Chandra, now in her third year at the School of Medicine, admits the initial objectives of the student group were a bit ambitious, especially given the rigors of medical school, but she and others believe the educational value of community service adds to their academic experience.

Students for Healthy Communities was established about the time Wayne State initiated its Co-Curricular Credit Program. Designed to encourage students to support the university's extraordinary commitment to the Detroit community, the program requires students to complete at least 75 hours of community outreach, including six extracurricular seminars, 25 hours of volunteer work and 25 hours of volunteer service. The seminars may cover diverse topics such as public policy and public health, alternative medicine and teen pregnancy.

"Through this process I've learned a lot," Chandra says. "I've learned how important the other players are (on the health care team). It has opened my eyes to realize that the physician isn't the key player. It's a team relationship. Issues that concern community members may or may not be the same as what we as physicians have been taught."

For Chandra, the ideal model of health care delivery is communication.

Curi Kim, a second-year student and leader in the Multicultural Girls Shadowing Health Care Professionals at the Detroit Medical Center program, believes the time she's invested in learning about community resources and how to strategically work with elements of the community will help her as her medical career develops. "It will make us better physicians, in terms of looking beyond the individual's presenting complaint. We're learning to look at the whole person in the context of their community.

"This experience is helping me to realize that there are other resources in the community (besides traditional health care services)." The definition of health, she says, is broader than just individual medical care. "To improve health involves other factors, such as social well-being."

The multicultural job shadowing program introduced 23 young women from local ethnic communities to various health care professions. The women were African American, Senegalese, Bengali, Pakistani, Indian and Kosovan, and represented the Muslim, Christian and Sikh faiths. The two-month project involved six-hour weekday sessions at hospitals in the Detroit Medical Center, including morning educational sessions and afternoon job-shadowing of all clinical fields, including the laboratory and medical library. In addition to professional rotations, the young women attended classes in health promotion skills, self sufficiency, self esteem, cultural awareness and career development.

"I don't know how many medical schools emphasize community outreach to the extent that Wayne State University does," says Kim. Compared to the nation's more than 100 medical schools, Wayne State has one of the largest student outreach programs.

"What really amazed me this summer, though, was the support I received from physicians and other health care professionals for this shadowing program. Some of them really went above and beyond my expectations with their interest and helpfulness."

Deborah Czarski, a second-year student developing the reproductive health component of the mini-medical school program, agrees. "One of the reasons I was interested in attending Wayne was its community outreach curriculum."

Community outreach literally provides an outlet for students absorbed in the academic world. "There is a lot of academics in the first two years of medical school," she says. "There's not a lot of interacting with people you're going to serve. I was working in the clinic with community people who weren't sick but wanted to improve their health status.

"I'm learning how you can approach a community and work with a community and have them trust you to help them. In the community of Detroit, trust is a big issue."

The mini-medical school concept grew out of the observation that health education among middle and high schools is severely lacking, according to Czarski. The goal is to provide students an overview of the core subjects in medical school, in a way that links them to everyday life. For example, the science of neurology is linked to drug abuse and head injuries. Respiratory physiology is linked to exercise.

The co-curriculum challenges students to develop a balance between community service and educational demands, while preserving some sort of personal life as well. 

"This is a tough period for me in class," notes Czarski. "That's the toughest part (of outreach). I can't study all the time and do community projects. I have to have my friends and private life. It's hard to balance. I wonder whether I'd be studying if I wasn't doing this. Sometimes the strain of designing a new program can be overwhelming."

While outreach also challenges Chandra's academic time, her commitment to community health is often as strong as it is to academics. The only time she has to withdraw from community work is during time-intensive rotations like surgery--which, she says, makes outreach "next to impossible."

"I've gotten myself in so deep it would be very difficult to let go," Chandra says. "This has become my ideal of what health care should be. For anyone else, it depends on how active they want to become. For the three of us, this is not something that will end in our fourth year, or in the rest of our careers."

The members of Students for Healthy Communities find themselves on the vanguard of subtle, but significant change in the relationship between individual health and social health. As population-based medicine and the role of social behavior become a greater part of a physician's practice, the nature of private and public health will blur. 

When these students enter practice, they're likely to refer to themselves as "community" physicians, Czarski suggests. "I don't see the distinction between community health and private health. The distinction is very blurred."