INTRODUCTION
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.
HYGIENE
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.
PREVENTIVE MEDICINE
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. Thus, the term preventive medicine is regarded as synonymous with public health.
SOCIAL MEDICINE
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 4anatomy gives 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’).
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 Programme 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.
COMMUNITY DIAGNOSIS
Definition
Community diagnosis is defined as (WHO) “quantitative and qualitative description of health of citizens and the factors which influence their health”. It defines problems proposes areas for improvement and stimulates action.
Community diagnosis is the foundation for improving and promoting the health of the community members, by identifying the factors affecting the health of the population and determining the availability of resources within the community to adequately address these factors. Thus, community diagnosis is a useful tool to assist in the work of healthy cities project.
Relevance
Community diagnosis has the following relevance:
- Acts as a data reference for the district
- Provides overall picture of the local community
- Suggests priority areas for intervention and feasible solutions
- Indicates resource allocation and the direction of work plans
- Creates opportunities for intersectoral collaboration and media involvement
- Forms the basis of setting indicators for healthy cities project evaluation.
Purpose
The purpose of community diagnosis is to define the existing problems, determine available resources and set priorities for planning, implementing, and evaluating health action by and for the community.
Stages
The process of community diagnosis involves four stages:
- Initiation
- Data collection and analysis
- Diagnosis
- Dissemination
Initiation
A working group committee should be set up to initiate the community diagnosis project, involving government department, health professionals, and nongovernment organization.
Available budget and resources should be identified. Areas to be studied include health status, lifestyles, living conditions, socioeconomic conditions, physical and social infrastructure, inequalities as well as public health services and policies.
Then working schedule should be set.
Data Collection and Analysis
Both qualitative and quantitative data is collected from a large sample size of the population through survey. Data should include population size, age and sex structure, medical services, public health, social services, education, housing, public security, transportation, etc.
Data is analyzed and presented as follows:
- As rates and ratios for comparison
- Trends or projections to monitor over a time period for future planning
- To compare with other districts
- Geographical presentation can also be done for easy understanding.
Thus, analysis of data defines needs, strengths, barriers, opportunities, readiness, and resources. In short, it is the community profile.5
Diagnosis
Diagnosis should comprise three areas:
- Health status of the community
- Determinants of the health of the community (social, environmental)
- Potential for healthy city development.
Dissemination
The report is put into communication. The target audience for community diagnosis includes policy makers, health professionals, and the general public. The report is disseminated through the following channels.
- Presentations at meetings of health boards and committees, voluntary organizations, local community groups and the public
- Press release
- Health fairs and health promotion program.
Thus, community diagnosis is a comprehensive assessment of the health status of the community and is a dynamic process leading to health promotion in the community. Therefore, community diagnosis should be conducted at regular intervals.
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.
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.
|