Community Medicine with Recent Advances AH Suryakantha
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1Basic Concepts of Community Medicine
  • Introduction to Community Medicine
  • Concept of Health
  • Concept of Disease
  • Concept of Prevention

Introduction to Community MedicineCHAPTER 1

Community medicine is that branch of medicine, which deals with the study of provision of preventive, promotive, curative, rehabilitative and evaluative services to the community at large, through an organized comprehensive health care delivery system.
The goal is to identify the health problems and needs of the defined population (community diagnosis) and to provide the comprehensive health care (preventive, promotive, curative and rehabilitative services) in an organized manner followed by the evaluation of the services.
The term community medicine is only a new terminology. It is the successor of the terms hygiene, preventive medicine, social medicine and public health.
This word is derived from Greek word ‘Hygiea’, the Goddess of Health. Her disciples were called hygienists, who practiced hygiene for health. Hygiea is represented as a beautiful woman, holding in her hand a bowl from which a serpent is drinking. In Geek mythology, the serpent testifies the art of healing, which symbol is retained even today. During ancient days, due to lack of knowledge about disease causation and spread, hygiene and cleanliness was the only option for the promotion of health and prevention of disease. Hygiene is defined as ‘the Science of health and embraces all factors contributing to healthful living’. Hygiene continued to be in prominence until further knowledge about disease causation was acquired.
Later, when ‘germ theory of disease causation’ came to light, in 1840, the term, ‘Public Health’ came into general use, directed towards the maintenance and improvement of the health of the people. In 1920, Professor Winslow defined public health as ‘the science and art of preventing the disease, prolonging life and promoting health and efficiency through organized community efforts, such as control of communicable disease, sanitation, health education, etc. so as to enable every citizen to realize his birth-right of health and longevity’. Thus, the importance of preventing the disease was highlighted. The interventions were applied to healthy persons so as to prolong life. Thus, the scope was broadened.
The discoveries in microbiology in the turn of 18th century became a turning point in the etiological concept of disease. Possibility of disease prevention first came to focus when James Lind, while traveling in a ship in 1748 conclusively showed that scurvy can be prevented by the use of fresh citrus fruits. Cellen reported that he himself drank milk inundate with mercury to prevent syphilis. But the major thrust came with the discovery of smallpox vaccine by Edward Jenner. Thus, the concept of preventive medicine was developed as a branch of medicine distinct from public health, based on etiology, applied to ‘healthy’ people for the control of infectious disease in the community.
Leavell and Clark defined preventive medicine as ‘the science and art of preventing the disease, prolonging life and promoting physical and mental health and efficiency’.
Thus, the scope of preventive medicine was broadened from the general measures of health promotion (i.e. Hygiene) to specific measures of disease prevention by immunization, including both.4
Thus, the term preventive medicine is regarded as synonymous with public health.
This term was first used by Jules Gurein, a French physician in 1848. However, it was during 1911, Alfred Grotjahn of Berlin who stressed that social factors play a dominant role in health and disease.
Social medicine is defined as, ‘The study of man as a social being in his total environment’ (Physical, biological and social environment). Thus, social medicine became an extension of preventive medicine.
Social medicine achieved academic respectability in England, when John Ryle was appointed as the first Professor of Social Medicine at Oxford University in 1943, and Professor Crew at Edinburgh. This subject consists of the following components:
  • Social anatomy
  • Social physiology
  • Social pathology
  • Social therapy.
Social Anatomy
Just like human anatomy, deals with the structures of the body, so also social anatomy deals with the structure of the society, which consists of total population, their age and sex-wise distribution, socioeconomic classification, types of housing, occupation, industries, temples, schools, etc. The study of social anatomy gives a background information in understanding health and disease phenomena in the community.
Social Physiology
Just like human physiology deals with the functions of the body, so also social physiology deals with the functions of the society. The various aspects of human physiology and the corresponding aspects of social physiology are shown in Table 1.1.
Social Pathology
Just like human pathology, deals with the study of abnormal structure of the body organs, the social pathology also deals with the study of defects in the society such as strikes, lock-outs, theft, murder, robbery, sexual assault, juvenile delinquency, etc. and just like the extent of pathology is studied by postmortem studies so also the extent of social pathology in the community is studied by social postmortem, which consists of morbidity and mortality (disease and death) surveys. Such surveys also help us to understand the social factors responsible for the prevalence of the disease in the community (explained under ‘Sociology’).
Table 1.1   The various aspects of human physiology and social physiology
Human physiology
Social physiology
Air, ventilation, housing
Nutrition and health
Disposal of refuse, sewage excreta, dead-bodies, etc.
Family welfare services
Demography and population dynamics
Customs, habits, traditions, beliefs, cultural practices, etc.
Social Therapy
Just like medical therapy (treatment) consists of administration of drugs, so also social therapy consists of adoption of social and political actions in the community. Social action consists of giving health education to the community, launching immunization program improvement of sanitation, etc. so that the people become health conscious, vaccine conscious, latrine conscious, water conscious, etc. Political action consists of implementation of certain legal measures for the health, safety and welfare of the people. Examples for heath legislations are Medical Termination of Pregnancy Act (MTP-Act); Prevention of food Adulteration Act (PFA-Act); Employees' State Insurance Act (ESI-Act); Indian Factories Act (IFA), etc.
This consists of identification and quantification of health problems, in terms of morbidity and mortality rates (disease and death rates) and their influencing factors in a community. This helps to prioritise the health problems and implement control measures. On the other hand, when a diagnosis is made in an individual by the doctor based on signs and symptoms, it is called ‘clinical diagnosis’. The differences between clinical diagnosis and community diagnosis are shown in Table 1.2.
Community and Hospital Medicine
There are two areas of work for the physician, viz. community medicine and hospital medicine. The differences are given in Table 1.3.
Table 1.2   Differences between clinical diagnosis and community diagnosis
Clinical diagnosis
Community diagnosis
Made by the doctor (Physician)
Made by the epidemiologist
Concerned with individual case
Concerned with a defined population
Concerned with only sick people
Concerned with both sick and healthy people
Doctor examines the patient
Epidemiologist conducts surveys
It is arrived at based on signs and symptoms
It is arrived at based on natural history of disease
It involves laboratory investigations
It involves epidemiological investigations
Doctor decides the treatment
Epidemiologist decides the plan of action
Treatment is the main aim
Prevention and promotion is the main aim.
It involves follow-up of case
It involves the evaluation of program
Doctor is interested in technological advances
Epidemiologist is interested in statistical values
Table 1.3   Differences between community medicine and hospital medicine
Community medicine
Hospital medicine
Service area
Provides health care to the people of defined geographic area
Draws patients from ill-defined catchment area
Operational strategy
Both active and passive operational strategies are applied, i.e. both providers and consumers are on the move
Only passive operational strategy is applied, i.e. responsibility lies on the patient to come to hospital for treatment
Organizational framework
Consists of Community Health Centers, Primary Health Centers and Subcenters
Consists of a loose conglomeration of primary, secondary and tertiary care hospitals
Nature of care
It is comprehensive (i.e. preventive, promotive, curative and rehabilitative)
Only curative care, leading to freedom from illness
Intersectoral coordination
Exits between the health department and the health-related departments
Virtually no intersectoral coordination exists
Program participation
Promotes active participation in the operation of National Health Programs
Has limited scope in the participation of National Health Programs
Cost-benefit analysis
Gives high cost-benefit ratios by involving minimum expenditure and yielding maximum results
Gives poor cost-benefit ratios by involving maximum expenditure and yielding minimum benefits
With the emergence of noncommunicable disease such as hypertension, diabetes, cancer, accidents, etc. and due to their multifactorial etiology, the concept of ‘multifactorial disease causation’ came into vogue. So, measures like early diagnosis, identification of risk-factors, limiting the development of disability and rehabilitation of handicapped persons were included in the subject. Thus, the scope was broadened from hygiene to preventive and social medicine and now to community medicine. Thus, the concept of community medicine came into vogue.
Whatever may be the terminology, the ultimate goal is to prevent the disease, promote the health and to prolong the life of the people. This is based upon the principle that ‘Prevention is better than cure’. Not only prevention is better than cure, but also it is simpler than cure, safer than cure, cheaper than cure and easier than cure. This is a universal truth.