Curriculums must include social determinants of health, say Téa E Collins, Svetlana Akselrod, Julia Tainijoki-Seyer and Ayodele Akinnawo
Non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are on the rise in poor and rich countries alike. These four main groups of NCDs are responsible for 41 million deaths worldwide, with 78% of deaths from NCDs occurring in low and middle income countries (LMICs). 
NCDs are preventable, and many preventive activities target the modifiable behavioural risk factors of NCDs, such as poor diets, smoking prevalence, harmful use of alcohol, and a lack of physical activity. Not enough attention is given to the social determinants of health.  Most of these determinants, such as poor early life experiences, education, income, and working life and environmental conditions, have a negative influence on people’s health and length of life and contribute to the increasing burden of NCDs worldwide. 
There are a number of actions and strategies which are beyond the remit of health systems that can be implemented to influence the social determinants of NCDs.  There is also more that could be done to explore the role of social determinants within the health sector itself to tackle NCDs, particularly in terms of making sure that physicians’ training is fit for purpose.
The common approach to medical education has a disease focus and narrow contextual understanding. Traditional curriculums are not designed to demonstrate the links between living conditions and diseases, and treatment is often emphasised over disease prevention. LMICs are experiencing rapid demographic and epidemiological transitions and need a healthcare workforce that is able to respond to the current global health challenges in clinical settings. We propose that medical education needs to change to prepare future physicians. A “transformative” medical curriculum needs to explore the convergence of public health and medicine by taking a holistic view of a patient, as well as incorporating population level attributes. It should be context specific and integrate teachings of global health, social determinants, and medical science with increased interest in underserved communities. 
Physicians need to be trained to incorporate the social determinants of health into their clinical practice by combining a biomedical education with an approach that builds critical thinking through interprofessional, cross-sectoral, experiential learning opportunities throughout the curriculum and future professional development. 
Collaborative education is a cornerstone of transformative learning. The importance of interprofessional teamwork in healthcare systems is increasingly recognised as a means to achieving higher quality care and improving the effectiveness and efficiency of services.  Moreover, enhanced collaboration among healthcare professionals with complementary skill sets is prerequisite to improving coordination and continuity of care for chronic NCDs. However, medical education systems often remain ill equipped to train students in interprofessional teamwork. Evidence indicates that most education systems limit the development of positive relationships among students of different professions, thus restricting their understanding of and respect for others’ roles and perpetuating non-collaborative practices. 
It is also important for physicians to foster dynamic, close working partnerships with people outside the health system, such as policy makers, educators, and community organisations, as there are key to addressing social determinants. Collaboration between health and non-health professionals can be supported by effective leadership, a shared vision, strong relationships among partners, and efficient structures and processes to do the work of collaboration. 
Increased advocacy towards the inclusion of social determinants of health in medical courses would help to create the needed policy change. Collaboration between ministries of education and ministries of health will be essential to transform medical education. These changes should be introduced according to regional, national, and institutional needs and consider the culture, teaching traditions, disease burden, healthcare delivery models, and availability of resources.
Additionally, using their dual capacity as health experts and trusted members of society, physicians are particularly well positioned to act as proponents for individuals, communities, and the healthcare profession. Acting in their own capacity, or through their affiliation with professional bodies such as medical associations, they are able to put pressure on governments to implement policies that will reduce health inequalities.
It will take time to change the practice of healthcare to make disease prevention a part of clinical care. We need to recognise the multiple determinants of health, improve access to healthcare for those with unmet needs, build interdisciplinary and interprofessional partnerships, and advocate for public policies that promote the health of all communities. Changing medical education to a “transformative” model is a step in the right direction.
Competing interests: None declared.
This article is part of a series proposed by the WHO Global Coordination Mechanism on NCDs and commissioned by The BMJ, which peer reviewed, edited, and made the decisions to publish. Open access fees are funded by the Swiss Agency for Development and Cooperation, International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), UNOPS Defeat-NCD Partnership, Government of the Russian Federation, and WHO.
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