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Community Medicine: A Students Manual
First Edition: 2015
Community medicine is not something medical students (at least the majority of them) enjoy studying very much. Of all medical specialties, it has the distinction of being most deglamorized. However, in this age of increasingly super specialized medicine, community medicine is the sole voice speaking for primary health care, holistic approach to medicine and the role of preventive medicine. It is essential that in their disregard for the subject, present day medicos do not completely ignore such fundamental and brutally important aspects of medicine.
It is with this aim in sight that I had set out to write this book, essentially a compendium of my class notes. As the title implies, I have tried to maintain a student’s perspective throughout. But as much as I have tried to be succinct, the very informative nature of the subject, along with ongoing advances have resulted in a slightly larger volume than my expectations.
I hope students enjoy the book, and appreciate the concepts herein.Acknowledgments
- To the members of Department of Community Medicine, Radha Gobinda Kar Medical College, Kolkata, India (2005–2007); for I have borrowed their methods of teaching, and often their material. Specifically, Dr DK Das, Professor AB Biswas, Dr GN Sarkar, Dr RN Roy, Dr Sujishnu Mukherjee, Dr Prabha Srivastava, Dr Sarbajit Roy.
- To Professor Arnab Sengupta, for inculcating the ideas of social medicine into me.
- To wikipedia (en.wikipedia.org), the National Library of Medicine (nlm.nih. gov), and the Centers for Disease Control and Prevention Public Health Image Library (phil.cdc.gov) from where I have borrowed several images and references.
- To Professor Sujit Kumar Chowdhury, DR Lawrence, PN Bennett and MJ Brown, whose methods of writing I follow rigorously.
Never have people lived so long, or been so healthy, and never have been medical achievements so great, as the 21st century. Yet paradoxically, rarely has medicine drawn such intense doubts and disapproval as today.
—Cambridge Illustrated History of Medicine
Today, of all times, it seems that we have grown ‘used to’ the spectacular advances in medicine. We believe, we are the inhabitants of a free world, and our right to a long, healthy life is at par with our rights to education, democracy and free speech. Let us, if only for a few paragraphs, try to retrace our steps.
As all of you should be well aware by this age, this planet is not the right place for a gentleman (or woman) to be. Our existence is plagued continually by bacteria, diabetes, super-cyclones, famines, pollution, global warming, heart disease, viruses, militants and warmongers. Its no short of a miracle that our species has still managed to survive the time it has here. Times were not always so good as it is today. Most of human history is smeared with blood, sputum, phlegm and pus. Epidemics and outbreaks have periodically swept entire continents, men have succumbed to boils and carbuncles far too often, been hapless victims of calamities countless times, and killed each other over land far too frequently. It was only in the last century that we reflected upon the progress of our species, for the first time, and decided it was time to take control.
The first frontier to conquer was of course, germs. At the outbreak of the Second World War, penicillin was still at the laboratory stage and remained rationed for several years. Before the advent of ‘antimicrobials’, pneumonia, meningitis and similar infections were still frequently fatal. In combination, the development of vaccine initiated a two pronged attack on infections. Tuberculosis, the ‘white plague’ of Europe, was given the coupe de grace by the introduction of Bacillus Calmette-Guérin (BCG) vaccine and streptomycin in the 1940s. The first vaccines for poliomyelitis appeared in the next decade. Together, vaccines and antimicrobials proved to be an effective, if only temporary solution, to the infection nuisance.
This ‘pharmacological revolution’ was extended on to a broad front in 1950s. The new biological drugs beat the bacteria, improved the control of deficiency diseases, and produced effective medications for many emerging noncommunicable disease (i.e. chlorpromazine, diuretics, digitalis). The new fields of plastic and transplant surgery were opened by steroids who tackled the rejection problem.
Meanwhile, research in basic science transformed our understanding of battle with disease. Notably two inventions, the discovery of deoxyribonucleic acid (DNA) structure (Franklin, Watson and Crick) and the cracking of genetic code (Har Govind Khurana), not only helped scientific progress but also left a lasting impression on the public imagination. Finally, it seemed that we have the key to a healthy life, eradication of all diseases and even immortality. Things were looking good.
The ushering of the medical market
It was about this time since medical ‘specialties’ started to grow and form a lasting image over public imagination. Cardiology made its first breakthrough by surgical intervention of congenital cyanotic heart disease in 1944. Open heart surgery dates from 1950; bypass surgery, from 1967. The rising trend of diabetes mellitus in urban population made ‘endocrinology’ emerge as a clinical discipline, and suddenly everyone was rushing for a postgraduate degree. By the 1990s, everyone was referring to doctors as ‘specialists’ in one or other field, and the statement“I am a doctor” was to be retaliated immediately by “Of what?”
The conversion of medicine from a social service to a ‘performing art’ was exemplified no better the development of surgery. By 1970s, surgery was beginning to resemble space travel—It seemed to know no bounds. Organ replacement developed first with kidneys; and then transplantation became a banner headline in 1967 when Christiaan Barnard sewed a woman’s heart into Louis Washkansky who lived for 18 days. By the mid 1980s, hundreds of heart transplants were being conducted each year in the US alone. Gone were the days of the good ol’ family physician, enter the new breed of superhealers. From a low profile, humble service-medicine was transformed into a headline generator and revenue service. Corporates, media and lawyers jumped into the medical melting pot, health insurance companies grew obscenely fat, hospitals grew shinier and expensive; physicians, once the friends of people, turned into solicitors and ‘consultants’. Every diagnosis, for them, is just a scan away, and every cure, a pill or an incision away.
It has not helped wither that technological breakthroughs as electron microscopes, endoscopes, computerized tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI), lasers, tracers and ultrasonograms (USG) have created a revolution in medicine’s diagnostic capability, but only at the price of increasing cost. Modern medicine has effectively banned people with a cash flow problem. What has further aggravated the problems are the litigations that now smear medicine, and the fear of being sued has lead to the practice of ‘defensive medicine’, that is to go through a battery of investigations (usually called ‘the workup’ in physician circles) rather than use of the clinical acumen, skyrocketing the cost of care even higher. Effectively, health itself has become the new disease. The creation of these health commodities allows them to be bought and sold like carrots and iphones. Future risks, for example, of diabetes, cancer, heart disease or mental illness can then be traded as derivatives, with the disease risk traded against the possibility of a new or cheaper treatment in the future.
Markets depend on units that can be bought and sold, so markets in health depend on breaking down healthcare services (investigations, procedures and prescriptions), health (e.g. biological values such as blood pressure and cholesterol) and illness (diabetes or cancer) into unit parts that are measurable and saleable. The challenge, according to market advocates, is technical. All they have to do is define and value those parts in order that they become commodities.
—A petition on “Keep the NHS public” website
So this is where we stand today: In spite of all the tremendous advances, an atmosphere of disquiet and doubt now pervades medicine. We find ourselves increasingly entangled in dystopia, no longer do we expect to live our dreams to the fullest, no longer do we expect a healthy and long life. No longer do we expect that our successors will have enough of food and fuel to support the entire population. No longer can we expect to return home safely when we go out to work. Our only feeble wish is to die a less painful death than those at US military prisons, Afghanistan, Somalia, Cambodia, Vietnam ... you could go on forever. Euphoria bubbled over penicillin, over heart transplants, and over the first test-tube baby—But no amount of scientific achievement has overshadowed greed, corruption and short sightedness of our species.
Only two things are infinite: The Universe and human stupidity. And I am not so sure of the first one.
The prospects of medicine
I never think of the future; it comes soon enough.
Now that the big battles against disease have been won, medicine is also more open to criticism. Worldwide, socialized medicine faces grave political risk; in the USA, insurance and litigation scandals dog the profession. In rich countries, the poor are often excluded from health services. In the developing world, for lack of international will, malaria and diarrheal diseases remain rampant. Diphtheria and tuberculosis are resurgent in the Union of Soviet Socialist Republics (USSR). Not least, the pandemic of AIDS destroyed any native faith that disease has been conquered.
There is a second, much larger issue looming over, much larger than the commercialization of medicine. After we have won over all the scourge and pestilence, what is now the aim of medicine? Where to stop? Is its prime duty to keep people alive as long as possible? Is its charge to make people lead healthy lives or just to cure them when they are ill? Or is it but a service industry, to fulfil whatever fantasies its clients may frame for their bodies for instance, a facelift or cosmetic remodeling? Is developing an HIV vaccine the best thing we could put our funds into? Is the rate of human population growth healthy for this planet? Medicine has reached the point where Hippocrates, William Harvey and Lord Lister could only have dreamt of. What next?
To put developments in a nutshell, two facts give powerful (if conflicting) evidence of the growing significance of medicine. First, the trebling of world population in the last 60 years no small percentage of which is caused by new medical interventions and preventions. Second, the introduction of the contraceptive pill, which, in theory at least, paved a simple and effective means to control that population.
—Cambridge Illustrated History of Medicine
The great divide of medicine presents another pressing problem. On one hand, you have the well-to-do classes, who live within an expanding medical establishment faced with a healthy population of its own creation. Thus medicine is directed to medicating normal physiology (such as menopause), to convert risks to diseases, to treat trivial complaints with fancy procedures. Patients want it, they want some intervention, ‘something to be done’ to them, they simply do not agree that the mole on their left shoulder is simply a mole and just that. In this age of litigations, doctors dutifully, and often wilfully comply to order that costly biopsy and staining procedure. The motto: Everyone has something wrong, everyone must be cured. On the flip side, you have millions rotting in poverty, hunger, illiteracy and social injustice. More and more doctors push each other for a berth in the urban money-mad-medical-machine, and the millions in dark in the depths of our country are tormented into second hell as ever, to be flocked into polling booths into the election season.
So comes social (community) medicine
Surely, modern medicine has all the right tools and methods, but the wrong policy. Could not it be rectified? People in Britain and France have done it. It is called socialized medicine. It is the notion that the health of oneself is not one’s own responsibility but the shared burden of the community, and when one gets sick others help him out (through taxes), so that he gets the best medical care. All this without a buck spent on treatment.
But the idea of social medicine is far more revolutionary that socialized medicine. The principles of social medicine are:
- To reorient the public mind and medical education on thinking about health rather than thinking in terms of diseases.
- To prevent, by community effort, the emergence of disease through simple interventions, lifestyle and community behavior.
- To free medicine from the shackles of big corporates and push it into every home, every kitchen, every toilet; to educate people on healthful behavior, to establish a bottom up health system through primary health care; to orient people that illness is not to be reported in a big five star hospital, but to your local health center.
- To socialize prevention, diagnosis and cure of diseases.
So how does all this jargon relate to me?
If I am not for myself, who will be for me?
If I am only for myself, what am I?
If not now, when? —Hillel
I know all this feels a little tiresome to read. But you, of all people, must initiate the change. You will be great clinicians no doubt, and great surgeons galore, but picture in your mind, if you will, the poorest of the poor you have seen, the sickest of cripples, the nastiest of lepers, the creepiest of AIDS patients, who will never be able to afford you on a pay per visit basis. It is a decision you have to make early—Do you want to exercise your great skills over the ivory tower off corporate medicine, or do you want to come down, if only once in a while, to those outside your clinic.
I do not really like quoting clichés, but I really cannot afford to miss out these famous lines—
… He who uses these (skill, knowledge, human understanding) with courage, humility and wisdom will provide an unique service for his fellow man and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this, he should be content with no less.
—Tinsley R Harrison
How to read this book
“and what is the use of a book,” thought Alice “without pictures or conversation?”
—Lewis Carroll, ‘Alice’s Adventures in Wonderland’
No book is complete, and this one even more so. However, you should have a comprehensive, if not detailed understanding of community medicine, after going through this one. It would suffice to say that God is in the details, but we really do not need to know God, do we? Try to identify keywords which I have emphasized. Try to make lists, as I have made, from clauses of definitions. Focus more on the diagrams than text, focus more on the flowcharts than details of individual steps. Ensure that you would be able to utter at least two or three sentences of any topic from this book, but cover everything. Try to make mind maps of your own, remember with pictures, not words. Ignore all the numbers and detailed statistics, they are here just for formality. This is the approach which has benefitted me most as a student, and I believe it will make you enjoy (a keyword) this subject as much as I have.