Concepts 1 evolution of com med

Concepts in community
Medicine
Dr Amita Kashyap
Senior Professor, Community Medicine

Objectives
By the end of these lessons you will be
able to understand:-
•How Community Medicine is
different then Clinical Medicine
•Its evolution
• What is Community Medicine/
Public Health/ Preventive and Social
Medicine and
•Its basic Concepts

Importance of Preventive and Social
Medicine/ Public Health
What is common in:-
• Swine flu
• HIV
• Typhoid
• Malaria
• Malnutrition
• Cancer
• Addiction

Renewal of Interest in Prevention,
Protection and Promotion of Health
Last 3 decades of the 20th century witnessed
renewal of interest in Public Health due to:-
• Continued Emergence and Resurgence of
Cmcble. Dis. and increase in Life-Style Diseases
• Realization that investment in Clinical Care;
though necessary; is comparatively less cost
effective.
• Implementing PH Methods; may be difficult,
time-consuming but bring maximum gains.

Clinical vs Preventive Medicine
Clinical Medicine
• Individual patient
• Clinician has to be an expert
of his clinical methods for
Dx and Rx of a patient
• Focus on Cure – Dx & Rx
• Resultant Cure or
improvement bring
immediate gratification
form him; his family and
friends and the community
at large
• Maximum Budget spent
Preventive Medicine
• Community as a whole
• PH expert has to be in
addition; a Leader, a good
manager and an expert
communicator.
• Focus on Health Promotion
and Protection and Disease
Prevention.
• Results are not easily
recognizable, measurable and
quantifiable
• Minimum Budget spent

In-spite of all this;
• Public Health/ Preventive Medicine has
undoubtedly been a major driving force in
furthering the cause of human health and
development.
• Simple Public Health measures like – Safe
Water Supply, Sanitary Excreta Disposal,
Vaccination and Vector control measures
has saved many more lives than would
have been saved by all the dazzling
advancement of curatives and diagnostics
put together.

Medicine
Noted historian Henry Sigerist defined
medicine as:
“Medicine, by providing health and preventing
illness, endeavors to keep individuals adjusted
to their environment as useful and contented
members of society; or by restoring health and
rehabilitating the former patient, it endeavors
to readjust individuals to their environment.”

Contd……
From this definition, medicine has two
components –
1. “The Promotive and Preventive” component &
2. “Restorative and Rehabilitative” component
• However there is no sacrosanct dividing line in
practice
• In broader sense Preventive medicine refers
to “Limiting” the progression of disease at
any stage of its course………..

Contd……..
• Initially, Preventive Medicine was identified
with “Control of Communicable Diseases”
• Measures of “Epidemiology”; demonstrated
the preventability of Non-Communicable
diseases as well.
• “Counseling and Behavior Change
Communication” techniques are its tools to
bring positive change in the community.

Preventive Medicine & Public health
The dividing line is hazy-
Preventive medicine is an overall science
while Public Health is an approach
When preventive efforts are focused on
population groups and utilizes the
approach of ‘organized community efforts’
it takes the shape of public health.

Public Health
• In public health problems are named
within the context of the community as a
whole
• This help in establishing Priorities and
Rational use of resources for the benefit
of the health of the population as a
whole by ‘Organized Community Effort’
with ‘Systematic Social Action’

CEA Winslow defined Public Health as
The science and art of preventing disease,
prolonging life and promoting physical health
and efficiency.
Example -
 Educating individuals in principles of personal hygiene
 Organized community efforts for the sanitation of the
environment, will control community infections,
 the organization of medical and nursing services for early
diagnosis and treatment of disease and
 The Development of Social System which will ensure to
every individual in the community, a standard of living
adequate for maintenance of health.

Preventive and Social Medicine
• Rudolph Virchow et al emphasized the
role of social factors in disease causation
and thereby in its prevention.
• Somewhere around the mid 20th century
it was realized that the Art & Science of
Preventing disease and Promoting Health
should be taught as independent subject
in medical schools (till then it was taught
as hygiene with medicine).

Preventive and Social Medicine
• Thus originated PSM – The preventive medicine
essentially combining the social aspects of
health & disease in its theory, practice and
teaching.
• Socialized Medicine: refers to the policy of
providing complete medical care (preventive as
well as curative), to all members of the society
(usually a nation) as a Govt. commitment
through public funds.

History of Medicine:
Ancient Times
• Primitive Man attributed disease & sufferings to
the wrath of God- “Supernatural theory of disease;”
• Indian medicine:
5000BC- Ayurveda (‘Tridosa Theory) emerged from
“Atharved”
800BC- Atrey (Takshila); great Indian physician &
Teacher
200 AD- Charak (Court physician of king Kaniska);
wrote “Charak Samhita” descibing some 500
drugs;(Rauvolfia before Reserpine).

Indian Medicine…..
• Up to 400AD- Shushrut k/a ‘Father of Surgery,’ “Shushrut
Samhita”; containing Surgery, Anatomy, Pathology,
Ophthalmology, Hygiene, Medicine and Mid-Wifery
• 800AD- Charak & Shushrut Samhita translated in Arabic &
Persian languages.
Hygiene was upfront-” Mohan zodaro”
• 800BC-600AD- Golden Age of Indian Medicine
Set Back occurred in Mughal period
• 10th Century AD- Unani & Tibb (originated in Greece),
introduced by Muslim Rulers
• 1810-1839AD- Homeopathy (originated in Germany),
introduced by Europeans

Chinese Medicine: (2700 BC)
• Principle - “Yang” (Active Masculine Factor)
and “Yin” (negative Feminine Factor)-
balance= Good Health
• Tools were – hygiene, dietetics, hydrotherapy,
massages, immunization and drugs
• Integrated “Traditional Methods” with
“Modern Techniques”
• “Barefoot Doctors” & “Acupuncture”
known worldwide.

Egyptian Medicine:
The Art of medicine was mingled with Religion
• Specialization prevailed- in ‘eye, tooth, head
etc.’
• Principle- absorption of harmful substances from
intestine putrefy blood and formation of pus.
• Tools- Enema, Bloodletting and drugs
• Excelled in Public Health- Built public baths,
underground drains & planned cities.
• Knew association of plague with Rats, skull &
paralysis, worms, diabetes, rheumatism, polio
& smallpox Vaccination
• Recorded their work on ‘papyrus’

Greek Medicine:
460BC-136AD- civilizers of the ancient world
• Principle- “Theory of Humor” matter is build up
of four elements- Earth (cold), Air(dry), Fire(hot)
and Water(moist) & represented in body by four
humors- phlegm, yellow bile, blood & black bile.
The human body was assumed to have powers
of restoration of humoral equilibrium.
• Hygiea (PH) and Panacea (Curative) were two
daughters of Aesculapius (his staff; entwined by
a serpent continues to be the symbol of
medicine )

Greek Medicine……
• Hippocrates (460-370BC)- Challenged magic and
initiated “application of clinical methods”
• He studied & classified diseases based on
observation & reasoning; distinguished endemic
and epidemic diseases; (Epidemiologist seeking
causes).
• Taught us to think “Why & How.” He studied effect
of climate, diet, clothing, water, habits of eating &
drinking on health.
• Established relation between “Man & his
Environment”
• Hippocratic Oath- set standards for practicing
medicine.

Roman Medicine:
• By 1st Century BC center of civilization shifted to
Rome. Medicine built on Greek medicine.
• Public health developed- they built fine roads,
sewers, aqueducts, drained marshes to combat
malaria and established Hospitals/ medical schools.
• Galen (130-205AD); - emphasized importance of
Preserving health; since both in importance & in time
health precedes disease & curing disease
• He said disease is due to three factors-
– Predisposing, Initiating, & Environmental Factors
• Europeans accepted his writings as Text Books

Middle Ages(500-1500AD)- “Dark Age”
• Fall of Roman Empire lead to Abolition of Medical
Schools/ Hospitals, therefore diseases like T.B.,
Plague, Leprosy & Smallpox became rampant
• Medicine reverted back to “magic & superstition”
• Arabs developed “Unani & Tibb” with borrowed
knowledge from Greek & Roman.
• Abu Becr (Bagdad)865-925AD- also k/a “Razes”
observed pupillary reaction to light and published
book on child diseases, his book differentiating
smallpox & Measles is still respected.
• Arabs were seeking “Elixir of Life,” Pharmaceutical
chemistry developed.
• Built Hospitals with specialized departments.

After 1500AD- “Age of Revolutions”
• Fracastorius: Theory of “Contagion” - transfer of
infection via minute invisible particles & explained
the cause of an Epidemic. Recognized that Syphilis
is transmitted via Sex.
• Vesalius- Anatomy & Ambroise Pare- Surgery.
• 1540- united Co. of barber surgeons formed; later
became Royal College of Surgeons.
• 1628- Harvey; discovery of circulation of blood
• 1670- Leeuwenhoek’s microscope
• Morgagni; 1682-1771 founded pathologic Anatomy
• 1796- Jenner’s vaccination against smallpox

• 18th Century; Industrial Revolution slums
• Edwin Chedwick’s (a lawyer)report on “the sanitary
conditions of the labouring population in Great Britain”
same time Shuttak in America.
• 19th Century; “Great Sanitary awakening.”
• Public health Act 1848- The State has a direct
responsibility for the Health of the people.
• Concept of Public Health emerged properly- Jhon
Snow’s spot map for cholera deaths & Willium Budd
study on Typhoid fever concluded source of infection
even before causative organism was identified.
• France, Spain, Australia, Germany, Italy, Belgium, & the
Scandinavian countries all developed PH
• Developing Countries- slow growth of PH
• 1945 – WHO, initiated PH movements

Germ Theory of Disease (1873):
• Louis Pasteur, (1860) showed presence of
bacteria in air.
• Robert Koch 1877- showed bacteria of Anthrax
after that many other were demonstrated-
gonococcus, typhoid, pneumococcus, TB,
Cholera, diphtheria & so on
Preventive Medicine:
James Lind; 1753 for scurvy, Edward Jenner;
1796 developed vaccine for smallpox. In later
part of 19th century many more vaccines
developed.

• 1898; Ross demonstrated that malaria
was transmitted by Anopheles, then
Walter Reed et al identified Aedes for
Yellow fever, thus control measures
became specific e.g. – blocking
transmission channels e.g. destruction of
vectors & its breeding places, quarantine.
• With development of Laboratory Methods
“Early Diagnosis & treatment” was also
thought of as preventive measure.

• Tissue culture of viruses- Anti Viral Vaccines;
eradication of Smallpox in 1977 (Somalia).
• Discoveries in the field of Nutrition- control of
deficiency diseases.
• Discovery of Synthetic Insecticides.
• Discovery of Sulpha Drugs, Anti malarials, ATT,
Anti Leprosy drugs.
• Development of Chemoprophylaxis and Mass
drug treatment strategies.
• Concept of Screening – Syphilis, TB etc
• Screening for “Risk Factors”& identification of
“High Risk Groups”

Changing Concepts in Public Health
• 1880-1920 – Disease Control Phase
• 1920- 1960 – Health Promotional Phase
• 1960-1980 – Social Engineering Phase
• 1981 - 2000 – Health for All Phase
• Preventive Medicine- “health
promotion, Disease Prevention, Disability
limitation & Rehabilitation”

Concepts 1 evolution of com med

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