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 Table of Contents  
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 178-183

A picture speaks a thousand words: Using participant photography in environmental pedagogy for medical students

1 Institute of Community Medicine, Madras Medical College, Chennai, Tamil Nadu, India
2 Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India

Date of Web Publication23-May-2019

Correspondence Address:
Vijayaprasad Gopichandran
Department of Community Medicine, ESIC Medical College and PGIMSR, KK Nagar, Chennai - 600 078, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_124_17


Imparting a positive attitude toward social determinants of health among medical students has remained a challenge in medical education. This pedagogical exercise attempted to use a toxic tour with participant photography technique to impart environmental health education as part of the community medicine curriculum for medical students. In collaboration with a local environmental health nongovernmental organization, faculty from two medical colleges took a set of 13 medical students to Ennore thermal power plants as a part of a toxic tour to view the air and water pollution caused due to the operation of the power plants. The students were instructed to capture photographs of the environmental hazards using their mobile phone cameras and share them on a social media platform. Immediately after the tour, the students discussed their experiences with the faculty. Two weeks after the toxic tour, the students engaged in a focus group discussion in which they discussed their experiences, advantages, and disadvantages of the toxic tour and participant photography method and their attitudes toward environmental health. This pedagogical exercise led to the active engagement of the students with the environmental hazards in the area. They shared 70 photographs on the social media platform. In reflection, students described that they found the method very useful to actively engage with the environment, look for and find the hazards, revisit, and reflect on the photos, and use the photos to share the knowledge and experience. They also demonstrated a positive social determinants and public health attitude during the discussions. Participant photography technique during a toxic tour can impart affective domain of learning related to environmental health among medical students.

Keywords: Environmental health, medical education, participant photography, toxic tour

How to cite this article:
Subramaniam S, Gopichandran V. A picture speaks a thousand words: Using participant photography in environmental pedagogy for medical students. Educ Health 2018;31:178-83

How to cite this URL:
Subramaniam S, Gopichandran V. A picture speaks a thousand words: Using participant photography in environmental pedagogy for medical students. Educ Health [serial online] 2018 [cited 2022 Jan 29];31:178-83. Available from:

  Background Top

The medical curriculum as proposed by the Medical Council of India lays particular emphasis on building skills of medical students to understand, identify, and implement measures to assess control and prevent environmental hazards. Therefore, as part of the community medicine subject taught through the 1st–3rd years in the medical college, there are about 10 h of lectures and 20 h of field visits allotted to environmental health.[1] Innovations in the medical curriculum by pioneering medical institutions in the country have demonstrated the importance of field visits and practical hands-on learning of community medicine.[2] However, despite several models of practical and field-based training in community medicine, teaching a public health and social determinants approach to medical students seems to be a difficult task to achieve.[2] There is a need for innovative pedagogical tools to actively engage students in learning community medicine with a public health approach. One such method is the active use of participant photography as a pedagogical tool.

In keeping with the learning principle that learners should be active producers of knowledge, college education should actively engage students to participate with the community and generate knowledge that is relevant, contextual, and valuable.[3] In recent times, participant photography has been effectively used as a pedagogical tool in college education. It involves giving a camera in the hands of the students and having them photograph their surroundings that are relevant to what they learn.

Toxic tours have been a popular method of communication about environmental hazards and engaging communities by creating awareness about the hazards. It has been an effective tool for environmental advocacy.[4] Toxic tours are also important tools to teach environmental health. This paper describes an innovative pedagogical method where medical students were taken on a toxic tour to a thermal power plant in Chennai, South India, and were asked to use the participant photography method to document the various environmental hazards that they could observe around them. The teachers' observations of the learning process were documented. The findings of a posttour debriefing focus group discussion (FGD) with the students are also presented. The key objectives of this program included engaging students in an active learning process about the environment and imparting positive attitudes toward environmental health through the participant photography method.

The toxic tour and participant photography

This toxic tour with participant photographic method was initiated by the authors in their respective medical colleges. Thirteen students from the two medical colleges in Chennai volunteered to participate in this pedagogical method. Both the medical colleges are publicly funded institutions. One of the colleges is funded by the state government and the other by an employee's social security scheme. The students who volunteered were from the 2nd year and final year of their medical course. The students in the 2nd year were currently learning the environment chapter in community medicine and those in the final year had just completed the community medicine subject in their university semester examinations. There were a total of 2 women and 11 men in the group. Five of the men were from the 4th year and rest were from 2nd year.

The toxic tour was organized in collaboration with a nongovernmental organization, the other media, whose program called Community Environmental Monitoring (CEM) works to engage stakeholders in discussions on healthy alternatives to energy sources such as coal, nuclear, wind, and solar such that its impact on health and climate can be mitigated. One of the important campaigns on which the CEM works is to raise awareness and engage stakeholders on the adverse environmental impact of the thermal power plants in Ennore in the suburbs of Chennai.[5]

The thermal power stations were commissioned in Ennore to meet the energy requirements in Tamil Nadu in the year 1970. The station is located close to the Ennore port to receive the coal by ship. It currently has two 60 MW and three 110 MW power generation units and is the major provider of electricity for the state of Tamil Nadu.[6] However, due to the operation of these thermal power plants and poor implementation of environmental regulations in the area, recent years have seen massive air pollution in the Ennore area. Indiscriminate dumping of coal ash and proximity of the ash pond to the Ennore creek have led to substantial worsening of air and water quality in this area.[7],[8]

Before starting the toxic tour, the faculty described the purpose of the tour and instructed the students to use their mobile phone cameras to photograph all the important sights that they see around them that indicate the level of environmental hazard and pollution in the area. The students were then requested to share the pictures they took on a social media platform. The 13 students and the 2 accompanying faculties were the members of this social media group.

Two weeks after the toxic tour, the students were invited for a FGD to discuss in detail about their experiences in the toxic tour. Of the 13 students who went on the tour, only 6 could participate in the FGD. The other 7 were invited to participate but did not. This was because of an ongoing sports and cultural event that was happening around the same time. The FGD was facilitated by the author SD and VG was the observer who took extensive notes. Thematic analysis of the FGD was performed using a theoretical framework of learning using toxic tour and participant photography, developed by the authors by brainstorming and from previous literature. The theoretical framework is provided in [Table 1].
Table 1: Theoretical framework for analysis of the focus group discussions

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Photo sharing on the social media platform

The students shared a total of 70 photographs and 2 videos on the social media platform. The distribution of the scenes captured in these photos and the environmental hazard they depicted is shown in [Table 2]. Three sample pictures captured by the students are shown in [Figure 1], [Figure 2], [Figure 3].
Table 2: Description of photos captured by the students at the Ennore thermal power plant

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Figure 1: This photograph captured by the students shows slurry ash dumped into the Ennore river from the thermal power plant. The thermal power plant chimneys can be seen in the background

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Figure 2: This is another picture captured by the students showing the chimney of the thermal power plant spewing gases into open air

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Figure 3: This picture shows two students walking on the ash river, the river completely solidified by deposition of ash that has leaked into it

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Post-visit focus group discussion

The key findings of the FGD can be broadly classified into four major themes:

  • Experiential learning from the toxic tour and participant photography
  • Social conscience building
  • Benefits and harms of participant photography technique
  • Development of a public health and social determinants attitude to health.

Experiential learning from the toxic tour and participant photography

The students felt that the toxic tour helped them understand the extent of air pollution and water pollution that was happening due to the thermal power plant in the Ennore area. It made them experience the hazard in real time. One of the students said,

“I could perceive the dust in the air. I could feel it in my breath. The density of the dust in the air was strong.” – 2nd-year lady student.

Another student mentioned,

I had collected a flower there. One I had given to you (points to facilitator), the other one I had in my bag. When I took it out after coming back to my room and shook it, it had the ash dust.” – 2nd-year lady student.

Having visited the homes of some of the villagers in the residential area near the ash pond, the students mentioned that the villagers were breathing, eating, drinking, and living on the dust. The students identified with the problems of air and water pollution in the areas as they actively experienced it themselves.

Social conscience building

Some of the students engaged in discussions of social relevance during the debriefing FGD. One of the students initiated a discussion on the importance of striking a balance between “development” and social well-being. To what extent can social well-being be compromised for the sake of overall industrial and economic development of the state? He referred to the important need for electricity for the state of Tamil Nadu in order for it to develop as an industrial power. However, this development, he said, should not occur at the expense of environmental degradation and social illness of the people, as it is happening in Ennore. He said,

I realized that the government has been negligent. In the name of development, the government has allowed severe environmental damage. It has not kept the need of the people in mind. The local people have been neglected. The local PHC does not have facilities to treat the problems of the people. There is no respiratory care for the local people affected by air pollution.” – final-year male student.

Another student pointed out the key responsibilities of the government when such development projects are undertaken. He expressed disappointment when he said,

“…the maintenance of the thermal plants was poor. There was ash leakage which was not attended to. There was no proper disposal of ash and containment of air pollution. That is the main problem. It is a failure of government regulatory mechanism.”– final-year male student.

The students also engaged in discussions on lack of proper accountability mechanisms in the government. They referred to the poor awareness of people living in the area about the air pollution and its hazards. One of the students mentioned that it was imperative for the government to have engaged with the communities in a respectful manner before establishing the thermal power plants. They should have attempted to relocate them to less polluted places. Thus, the visit had led to significant reflections on social responsibilities and building of social conscience among the students.

Benefits and harms of the participative photography technique

The students perceived several important benefits of using the participative photography technique. They felt that the photos helped them focus on the environmental hazards. One of the participants mentioned,

“Taking photographs helped us focus and concentrate on all the important environmental problems in the area of the thermal power plant. If we hadn't been taking photos we probably would not have focussed on the problems” – final-year male student.

The other advantage of the participant photography technique perceived by the students was that rather than passively receiving knowledge, the process helped them actively look out and explore. One of the students said,

“Taking photos helped us search actively and look out for environmental problems. It helped us observe better and actively engage with the environment.” – 2nd-year lady student.

The photos also helped them recall the memories of the visit. Some of the students reported that they revisited the photos after they returned to their college and engaged in thinking and reflection of their visit and the environmental hazards. One of the participants explained how she used the photos to explain the problem of environmental degradation to her family. She said,

“I showed the pictures at home and explained it to my family. The photos helped me explain to them the effects of pollution. Without the photos it would have all been let to their imagination” – 2nd-year lady student.

Thus, the photos not only helped them actively engage with the environmental hazards, but it also helped them document, revisit, reflect, and share the knowledge.

One of the participants did mention that the photography technique distracted him from listening to the CEM member's narrative about the environmental hazards. Moreover, the attention to taking good quality pictures actually distanced him away from actively engaging with the environment. This was reported as a disadvantage of the technique.

Development of a social determinants attitude to health

During the discussion, the students demonstrated some important positive attitudes toward public health and social determinants approach to health. They demonstrated a broader social determinants approach to diagnosis and treatment of medical problems in their discussions. One of the students said,

“After the toxic tour, I felt that I should become a doctor and serve in the area and help the affected people. Alternatively, I can become an Indian Administrative Services officer and bring policy changes to improve the environmental conditions in the area” – final-year male student.

The tour and the photography engagement had also influenced the way they see patients in their outpatient departments during their clinical rotations. One of the students said,

“I am now asking the patients if they are from polluted area like Ennore. If they tell me they are, then I know that I have to expect respiratory problems” – final-year male student.

In a deeply reflective statement, one of the participants mentioned that she understood the importance of social determinants of health after actively engaging with the tour and the photography technique. She said,

“I have started realizing that medicines are not enough for treating health problems. Larger social understanding is essential, and social interventions are important” – 2nd-year female student.

During the concluding part of the FGD, one of the students remarked that it is important to engage with the children in the community to educate them and empower them such that they may be aware of their right to a safe environment and can question the authorities to take necessary action. All these discussions indicated that the students had engaged in deep reflections on environmental health issues and had developed a positive attitude toward broader social determinants of health.

  Conclusions Top

While all innovative pedagogical methods focus on imparting cognitive and psychomotor domains of learning, very few methods are available which can have an impact on the affective domain. Medical education often lags behind in helping students to develop a public health and social determinants approach.

This paper has described the value of a toxic tour with participant photography in the cognitive, affective, as well as psychomotor domains of learning. During the toxic tour, the students demonstrated greater engagement with the environment and exhibited an inquisitive tendency toward the environmental hazards. The photographs that they captured and shared on the social media platform demonstrated their attention to the major environmental hazards such as pollution of the Ennore river, discharge of fumes and gases from the power plant chimneys, ash pipe leakages, ash pond dump, and coal ash river. Among the 13 students who visited, a total of 70 photographs were captured and shared on the social media platform. This is an indication of the extent of engagement of the students with the environment and their observations. Further, during the postvisit debriefing FGD, the students actively engaged in discussing the environmental hazards, social responsibility of government to save the environment, usefulness of the toxic tour, and photographic technique in understanding environmental health. They also demonstrated a positive attitude toward a broader social determinants and public health approach to medicine.

The toxic tour and participant photographic method has its distinct advantages as discussed by the students who participated in the activity. The method is easy to adopt in a routine teaching–learning setting due to the ubiquitous penetration of camera mobile phones among youngsters. Effective engagement with the photos and well-facilitated discussions on the photos by trained facilitators can help learning in the affective domain. However, as described by one of the participants in the study, the participant photography can run the risk of too much attention to taking good photographs at the expense of actually engaging with the environment. This should be balanced by placing a cap on the number of pictures that a student can take, or by dividing the themes on which pictures can be taken, among the students.

This program provides some useful insights into the strengths and shortcomings of the toxic tour with participant photography method. It would be important to test this pedagogical method in a wide variety of settings and then recommend it for incorporation in the curriculum. Such innovations are essential to break the walls of the “ivory towers” of medical education and take medical teaching–learning to the community alongside the people.


The following students participated in the pedagogical exercise – Mr. Sanjai S., Mr. Gowtham M., Mr. Logamani P.K., Mr. Logesh, and Mr. Shashank Makarla, ESIC Medical College and PGIMSR, Chennai and Ms. Sundari A.S.M., Ms. Priyadarshini J., Mr. Kevin Rohith, Mr. Vasanth A., Mr. Prabhu R., Mr. Aravind Raj P., Mr. Vignesh K.N., and Mr. Sai Kishore, Madras Medical College, Chennai.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Medical Council of India. Medical Council of India Regulations on Graduate Medical Education. Available from: [Last accessed on 2016 Aug 20].  Back to cited text no. 1
Krishnan A, Misra P, Rai SK, Gupta SK, Pandav CS. Teaching Community Medicine to Medical Undergraduates – Learning by doing: Our Experience of Rural Posting at All India Institute of Medical Sciences, New Delhi, India; 2014.  Back to cited text no. 2
Kolstø SD, Bungum B, Arnesen E, Isnes A, Kristensen T, Mathiassen K, et al. Science students' critical examination of scientific information related to socioscientific issues. Sci Educ 2006;90:632-55.  Back to cited text no. 3
Depoe SP, Delicath JW, Elsenbeer MF (eds). Communication and public participation in environmental decision making. State University of New York Press, Albany, 2004.  Back to cited text no. 4
About Community Environmental Monitoring. Available from: [Last accessed on 2017 Apr 21].  Back to cited text no. 5
Jayabalan P. A Study on Power Scenario in Tamil Nadu. Chennai; 2014.  Back to cited text no. 6
Air in and Around Ennore Highly Polluted: Study. Chennai: The Hindu; 12 April, 2016. Available from: [Last accessed on 2019 Feb 20].  Back to cited text no. 7
Narain JT. In pictures: How a Power Plant Devastated the Pristine Beauty of a Creek near Chennai. Scroll; January, 2017. Available from: [Last accessed on 2019 Feb 20].  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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