Why Community Medicine?

Hippocrates on Epidemics
Timeless advice to physicians
who seek to determine of health and
disease
Whoever would study medicine
must learn
of the
following subjects:
 First
He must consider the effects of each
of the seasons of the year and the
differences between them.
 Secondly

He must study the warm and

the cold winds, both those
which are common to every
country and those peculiar to
a particular locality.
 Lastly

the effect of water on the

health must not be forgotten.
Just as it varies in taste and
when weighed, so does its
effect on the body vary as
well.
When, therefore, a physician
comes to a district
previously unknown to him,
he should consider both its
situation and its aspect to
the winds.
• The effect of any town upon the health of
its population varies according as it faces
north or south, east or west….
• Similarly, the nature of the water supply
must be considered; is it marshy and soft,
hard as it is when it flows from high and
rocky ground, or salty with a hardness that
is permanent?
• Then think of the soil, whether it be bare
and waterless or thickly covered with
vegetation and well-watered; whether it is
in a hollow and stifling, or exposed and
cold.
• Lastly, consider the life of the inhabitants
themselves; are they heavy drinkers and
eaters and consequently unable to stand
fatigue, or being fond of work and
exercise, eat wisely but drink sparely?
 Some Questions!
• Can Epidemics be controlled by Doctors sitting
in their clinics or hospital and treating those
whoever come to them themselves?
• Can they be controlled if health services are
exclusively limited within the domains of their
service outlets?
• Can they be controlled epidemics doctors alone
, even though they are the key agents in the
control of epidemics?
 Failure of Medicine
• Medicine is being criticized and questioned.
• Some critics have even described modern medicine as threat to health.
Their arguments are based on following facts:-

(1) With increased medical costs has not come increased benefits in terms of health

(2) Despite advances in medicine, the threat posed by some major diseases like
Malaria, Schitosomiasis, Leprosy, Filaria, trypanosomiasis , Leishmanisiasis etc,etc,.
has not lessened.

(3) Despite advances in medicine, infant and child mortality in developing countries
remain high.
(4) Evidence shows that significant improvements in longevity had achieved through
improved food supplies and sanitation long before the advent of modern drugs and
high technology.
(5) Modern medicine is elitist in orientation even in health systems adapted to
overcome social disparities
 The Shift towards Whole
(holistic approach)
• Medicine is regarded as an essential component of socio-economic
development.
• The goal of Modern Medicine is no longer merely treatment of
sickness.
• UNO set sustainable Development Goals including reducing
poverty and hunger, tackle ill health, gender inequality, lack of
education, access to clean water; and environmental degradation.
• Few goals are directly health related and other are indirectly
related to health.
• Community medicine is being regarded as a vehicle to achieve
these goals and have the leading role in modern medicine.
• The concept “ Agent, Host and Environment” embodies the holistic
approach.
 Why Holistic Approach?
• Clinical Medicine does not simply mean
prescribing a number of drugs.
• Neither it can limit itself to an individual
patient even if the aim is to cure his illness.
• Holistic approach implies not only integrating
medical domains but also calls non-health ones
like agriculture, industry, media, education,
law-enforcing agencies and many others to
achieve a healthy environment and society.
 From Reactive to Proactive Role
• Doctors if are restricted to their traditional
roles mere serves as diagnoser of ailment,
prescribers of pills and potions and exciser of
lumps.
• The world now calls on the doctors to be an
educator, case-finder, preventer , counsellor
and an agent of social change.
 Epidemiology
Focus on of Diseases
Community
Biostatistics
Health
Education
Anatomy Health Planning

Community Medicine
& Management
Mental Health
Focus on Screening &
Clinical Medicine
Individual Physiology Surveillance of
Diseases International
Health
Biochemistry Demography &
Family Planning Health
Economics
Pathology Environmental
Health

Pharmacolog Occupational
y Health
 Public Health Medicine

Primary Focus POPULATION INDIVIDUALS

PREVENTION DIAGNOSIS
HEALTH PROMOTION TREATMENT
Emphasis WHOLE COMMUNITY WHOLE PATIENT

INTERVENTION AIMED AT
Paradigm ENVIRONMENT, HUMAN BEHAVIOR ORGAN (CARDIOLOGY)
AND LIFE STYLE, AND MEDICAL
CARE

ANALYTICAL (EPIDEMIOLOGY) MEDICAL CARE

SETTING AND POPULATION
(OCCUPATIONAL) PATIENT GROUP (PEDIATRICS)
Organizational
Lines of SUBSTANTIVE HEALTH PROBLEM ETIOLOGY, PATHOPHYSIOLOGY
Specialization (NUTRITION) (ONCOLOGY, INFECTIOUS DISEASE)

SKILL IN ASSESSMENT, POLICY TECHNICAL SKILL (RADIOLOGY)

DEVELOPMENT, AND ASSURANCE
 Public health
"the science and art” of
• preventing disease,
• prolonging life and
• Promoting health
through the organized efforts and informed
choices of society, organizations, public and
private, communities and individuals.
 Key Concepts
&
Frequently used terms
 Defining Health

Patient –centered In terms of absence of disease and

approach defines disability

State of Complete
Population –centered Physical, Mental & Social Well-Being
approach defines as and not
mere absence of disease
 Agent
• A substance, living or nonliving, or a force, tangible
or intangible, the excessive presence or relative
lack of which may initiate or perpetuate disease
process.
• Categories:
• Biological Agents,
• Physical Agents
• Chemical Agents
• Nutrient Agents
• Mechanical Agents
• Social Agents
• A disease may have a single agent, a number of
independent agents or complex of 2 or more factors.
 Host
• A person or an animal, including birds and
arthropods, that afford subsistence or lodgment to an
infectious agent.
• An Obligate Host means the only host, e.g., man in
measles and typhoid
• Definitive Host: those in which the parasite passes it
sexual stage.
• Intermediate Host: those in which the parasite is in
larval stage or in asexual stage
• Transport Host: a carrier in which the organism
remains alive but does not undergo development
 Host Factors
1. Demographic characteristics
2. Biological characteristics
3. Social and economical characteristics
4. Lifestyle factors
 Environment
1. Physical environment
2. Biological environment
3. Psychosocial environment
 Concepts of Disease and Health
(Modeling interconnections of Disease & Health)
 Miasma Theory
• The  theory  that diseases such as cholera,
chlamydia or the Black Death were caused by
a miasma(Greek word for "pollution"), a
noxious form of "bad air".

Depiction of Spread of Cholera in 19th Century by the

spread of the disease in the form of poisonous air.
 Germ Theory
• Refers to the discovery in the late 19th century
that infectious disease are caused by
microorganisms.
• The theory supplanted miasma theory.
• There is 1 to 1 relationship between the
causal agent and disease.
Wheel of Causation
Multi-Causation Disease Model (Wheel of Causation)

Environment

Personality,
Beliefs &
Economics Behavioral choices Health care
system
Genetic
Endowment
Air pollution Water quality

Infectious
Disease
Outbreaks
 Multi-factoral Causation
• This approach asserts that diseases have many causes,
which may sometimes be present without the disease or
absent when the disease is present.
• It entails that there are many risk factors operating at many
different levels. Some exist at the societal level, others at
the community or neighborhood level, and some at level of
individual behavior or biological level.
• Prevention programs for multi-factorial diseases must be
designed to deal with as many of these levels as possible. 
 Web of Causation
ENVIRONMENT

HEREDITY SMOKING

Lung Cancer
DIET OCCUPATION

• This concept considers all the predisposing factors of

any type and their complex interrelationship with each
other .
• It shows variety of possible interventions that can be
taken to reduce the occurrence of chronic diseases
 Epidemiological Triad

(Vector)

The triad consists of an external agent, a host and an environment in

which host and agent are brought together, causing the disease to
occur in the host.
A vector, an organism which transmits infection by conveying the
pathogen from one host to another without causing disease itself,
may be part of the infectious process.
Another representation of Epidemiological
Triad
 Multi-factoral Causation
ENVIRONMENT

HEREDITY SMOKING

Lung Cancer

DIET OCCUPATION
 Iceberg of Disease
Tip of the Iceberg
(Diagnosed)

Submerged Portion
(Undiagnosed,
Subclinical cases,
Carriers, latent,
Pre-symptomatic)
• Examples which represent this model are many diseases including
hypertension, diabetes, anemia, malnutrition etc, etc.
• Hidden part constitutes an important, undiagnosed reservoir of
disease in the community and its detection and control is a
challenge to Preventive Medicine.
 PERIOD OF PRE-PATHOGENESIS PERIOD OF PATHOGENESIS
Human (Host) is not infected Course of Disease in Humans

DEATH
NATURAL HISTORY OF DISEASE

Environment Chronic State

Defect
Disability
Epidemiological Clinical Horizon
Illness
Triad Asymptomic Symptoms & Signs
Agent Host Tissue & Physiological
Changes
Immunity & Resistance
bringing Agent, host and Stimulus or agent becomes
established & multiplies RECOVERY
Environment together
Interaction of
results in the stimulus Host Reaction
Host & stimulus
In the Early Discernible Advanced Convalesce
Human Pathogenesis early Lesions disease nce
Host
Levels of
Secondary
Prevention Primary Prevention Tertiary Prevention
prevention
Modes of Health Specific Early diagnosis Disability
nterventionPromotion Rehabilitation
Protection & Treatment Limitation
 Risk factors
Attributes or Exposures that are:
significantly associated with the development of disease

That can be modified by intervention, thereby reducing the

possibility of occurrence of disease or other specified
Modifiable outcomes
Categories

Examples: smoking, high blood pressure, obesity , Increased

Cholesterol etc, etc,.

Examples: Age, Sex, Race, Family history, Genetic factors

Non-
Modifiable
They act as Signals in alerting health professional s to the
possible outcome
 Guidelines for Defining “at-risk” groups
Biological Situation
AGE groups • Infants (low birth weight)
• Toddlers
• Elderly
Sex • Females in the reproductive age group

Physiological state • Pregnancy

• Cholesterol level
• High Blood Pressure
Genetic factors • Family history of genetic diseases

Other health • Disease, physical functioning, unhealthy behavior

conditions
 Physical Situation
Residential •Rural
Background •Urban
•Slums

Living •Housing conditions

Conditions

Environment •Water supply

•Proximity to industries
 Socio-cultural Situation
Social Class •Poor
• Middle class
• Upper elite

Ethnic & cultural

groups
Family •Family disruption
•Education
circumstances •Occupation
•Housing

Cultural patterns •Customs

•Habits
•Life styles

Life Styles & •Customs

•Habits
Attitudes •Life styles
 “At risk” Population
Criteria for defining
At Risk Population

• Economic disadvantage
• Limited language competence
• Physical, cognitive, or sensory disability
• Cultural/geographic isolation
• Age & Gender vulnerability
 Forms of Occurrence of Disease
• Cases occur irregularly from time to time, and generally
infrequently.
• The case are few and separated widely in space and time and show
Sporadic little or no connection with each other, nor have a recognizable
common presence
• Constant source of infection.
of disease or infectious agent within a given
•• geographic
Examples: area
Polio,ortetanus, herpes
population zoster
group, and meningococcal
without importation from
Endemic outside.
• may also refer to the “ usual” or “ expected “ frequency of the
disease.
• Examples:
“Unusual”CommonoccurrenceCold. in a community or region of disease,
Epidemic specific health-related behavior ( e.g., smoking) or other
events (e.g., traffic accidents) clearly in excess of “expected
The term is used for a small, usually localized epidemic in the interest of
occurrence”.
Out break minimizing public alarm, unless the number of cases is indeed very large

• An epidemic affecting a large proportion of the population,

pandemic occurring over a wide geographic area such as a section of a
country, a continent or the world.
• Examples: Influenza , Cholera, TB, HIV-AIDS
 Control versus eradication
CONTROL
Reducing the prevalence of disease to a level
where
IT is NO MORE a major public health problem

ERADICATION
Reducing the prevalence of disease to Zero by
Termination of all transmission of infection
by extermination of infectious agent through surveillance and
containment
 Case A person in the population or
study group identified as
having the particular disease,
Carrier health disorder, or condition
A person
under or animal that
investigation . harbors a
specific infectious agent in the
absence of discernible clinical
disease
Susceptible
?
immune
?
Diagnosis
• ?
Identification of unrecognized
disease or defect by application of
Screening
tests, examination or other
procedures which can be applied
rapidly.

• D o n e o n a p p a re nt l y h e a l t hy .
 Population and Individual

• The population in question can be as small as

a handful of people or as large as all the
inhabitants of several continents (for instance,
in the case of a pandemic).
• Population in public health is defined on the
basis of risk
 Indicators
• Instruments to measure the change
(the various states of the things).
• Variables which are susceptible to
measure.
• A parameter measured repeatedly
over time to track towards objectives
• Variables which are susceptible to
measure.
 features of a good indicator
Valid it should actually measure the phenomenon it is intended to
measure

Reliable produce the same results when used more than once to measure
precisely the same phenomenon

Specific measure only the phenomenon it is intended to measure

Sensitive reflect changes in the state of the phenomenon under study

Operational be measurable or quantifiable with developed and tested

definitions and reference standards
 Types of Indicators used in Public Health
• There are many indicators. They will be the
most frequently found “devils” in the domain
of Public Health.
• Since indicators define magnitude of some
problem and are also used to compare the
problems between and among populations.
• Public Health is the most dynamic discipline in
all medical sciences, Indicators are the
mainstay to understand changes occurring
among populations.
Main Indicators used in Public Health

are related to
• Mortality
• Morbidity
• Disability
• Health care delivery
 Herd Immunity
• “The resistance of a group to invasion and spread of an
infectious agent, based on the immunity of a high proportion
of individual of the group”.
• During the course of an epidemic a number of susceptible
people come down with the disease, thus providing multiple
sources of infection to others.
• As the epidemic progresses the proportion of non-
susceptible ones increases and the likelihood of effective
contact between patients with the disease and remaining
susceptible declines.
• Herd Immunity can be quoted as an example of Public Good.
• An important consequence of herd immunity
is that , in general, it is not necessary to
achieve 100% immunity in a population in
order to halt an epidemic or control a disease.
• BUT THIS OBSERVATION IS NOT AN ABSOLUTE.
• Public health is what we, as a society, do
collectively to assure the conditions for people
to be healthy.
• The State of Debate : Scholars and practitioners are conflicted
about the “reach” or domain of public health. Some prefer a
narrow focus on the proximal risk factors for injury and disease.
• The role of public health agencies, according to this
perspective, is to identify risks or harms and intervene to
prevent or ameliorate them.
• Others prefer a broad focus on the socio-cultural-economic
foundations of health. Those favoring this position see public
health as interested in a more equitable distribution of social
and economic resources because social status, race, and wealth
are important influences on the health of populations.