Human resources section_1-textbook_on_public_health_and_community_medicine


Published on

AFMC WHO Textbook Community Medicine

Published in: Health & Medicine, Education
1 Like
  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Human resources section_1-textbook_on_public_health_and_community_medicine

  1. 1. 10095752550
  2. 2. Section 1 : Introduction and General Concepts in Public Health, Community Medicine & Preventive Medicine Introduction, Definitions & General Concepts in RajVir Bhalwar, Mandeep Singh,1 1 Public Health & Community Medicine J Jayaram2 History of Public Health Leo S. Vaz 8 Theories of Disease Causation, Natural History3 RajVir Bhalwar 17 of Disease & Levels of Prevention Measuring the Level of Health in a Population : Epidemiological4 RajVir Bhalwar 27 Measures (Indicators) of Health and Disease in a Community5 Classification of Diseases Vijay K. Bhatti 35 Philosophy Behind “Health For All (HFA)”, “Primary Health Leo S. Vaz, Sunil Agrawal,6 38 Care (PHC)” & “Millennium Development Goals (MDGs)” RajVir Bhalwar Public Health in Developing Countries and Countries with7 Amitava Datta 42 Transitional Economies - History, Development & Policies8 Public Health in Developed Countries Amitava Datta 479 State of Health in the World : Disparities and Divides Sunil Agrawal 5110 State of Health in India : National Health Profile Sunil Agrawal 59
  3. 3. the 20th century, many times more lives have been saved and Introduction, Definitions & diseases prevented by simple public health measures as safe 1 General Concepts in Public Health water supply, sanitary excreta disposal, vaccination and insect- & Community Medicine vector-control measures, than would have been saved by all the dazzling advancements of curatives and diagnostics put together! For instance, as per a report, the life expectancy in RajVir Bhalwar, Mandeep Singh, J Jayaram USA increased from 45 years in beginning of 20th century to over 75 years in the next 100 years and only 5 out of theseThe last two decades of the 20th century saw a renewal of 30 years increase can be attributed to the work of curativethe world population’s interest in public health, in disease medical care system, while the large majority of this gain hasprevention, communicable and chronic disease control, health come from improvements in public health, broadly defined toprotection and health promotion. Not that public health is a include better housing, nutrition, sanitation, immunizationnew concept; great public health movements had already and occupational safety (4).started in mid-nineteenth century by Edwin Chadwick inUK (report on an inquiry into the sanitary conditions of the Definitions & Basic Conceptslabouring population in great Britain, 1842) and around the At the outset it would be worth-while to review the meanings ofsame time in USA in 1850 by Lemuel Shattuck (Report of some terms in common use in the disciplines of public health,the sanitary commission of Massachusetts) (1,2). These two preventive medicine & community medicine. In fact, meaningsreports initiated that brilliant movement - now known as public change with time. Terms which have been long in use acquirehealth, of which preventive medicine is an essential component extended meanings (a case in point is the term “Preventiveand which has been responsible for saving billions of human Medicine” itself), while new terms are coined to signal a newlives and reducing human suffering during the last 100 years. emphasis. The meanings of some terms may overlap andThe recent increasing interest in public health shown by different shades of meanings may be associated with use ofnearly all governments, whether from developed or developing the same term. In fact, Public Health, Preventive Medicine andcountries has been, therefore, due to the realization of the fact Community Medicine contain very overlapping ideas as wouldthat continued investment in clinical care brings diminishing be evident throughout this book; accordingly, their definitionsreturns, while the gains can be maximized by resorting to are quite likely to overlap.methods of health promotion and disease prevention amongpopulations at large. HealthThe handicap that public health and preventive medicine There are many views as to what constitutes “health”. One viewalways face is that its predominant focus on prevention makes puts it as “absence of disease”, i.e. there are no impediments toit more abstract than curative medicine and its achievements an individual’s functioning or survival. This view is reflectedare therefore more difficult to recognize. The doctor who cures by Oxford English Dictionary (5) which defines health as thea patient has achieved a real, recognizable benefit and the state of being free from illness or injury. Implicit in this view ispatient, as well as her near ones and even the community a set of abilities that favours growth and development and themembers, are all grateful. On the other hand, public health efficient performance of bodily function in the face of changingcannot point to the people who have been spared of illness by environmental conditions, a capability known as “adaptability”.it’s efforts. As the famous quote goes “---- If we had but the As a corollary, disease corresponds to failures or disturbancesgift of second sight to transmute abstract figures into flesh and in growth, development, function and adjustments of theblood, so that as we walk along the street, we could say, “that organism, as a whole or any of its systems (6).man would have been dead of typhoid fever”, “that woman The problem inherent in the “absence of disease” definitionwould have succumbed to anaemia of pregnancy”, “that rosy is that it focuses only on disease. However, there is, in everyinfant would have been in its coffin because of diarrhoea and disease, a long phase of transition from actual health to thedehydration”, -then only would we have a faint conception overt disease process, as will be appreciated when one goesof the silent victories of public health-----“. In fact, it is this through the chapter on “natural history of disease and levels“silence” that accounts, in large part, for the lack of attention of prevention” in this book. Hence, health is something muchpaid to public health by those who are in a position to mobilize more than the mere absence of opinion or take public decisions. In developing The above ethos is echoed in the widely used definition ofcountries not even one percent of the total national budget is health by WHO, which states “Health is a state of completespent on public health; the situation, even in the developed physical, mental and social well being and not merely thecountries is no better. For example, even in USA, just about absence of disease or infirmity (7). This definition is commonly1% of the nation’s total health spendings go towards public seen as the statement of an “ideal” towards which nationshealth. In 1992, when the average cost of medical treatment should aspire, rather than as a practical working definition. Forwas $3,007 for each American, the amount spent on public this reason, an “operational” definition of health, one drawnhealth was only $ 34 per person (3) ! from the above “ideal” definition, has been forwarded, by aDespite the above-mentioned difficulties that public health technical study group of WHO (8). According to this definition,including preventive medicine, as a concept and as a science, is the concept of health is viewed as being of two orders - first,faced with, it has undoubtedly been a major force in furthering in a broad sense, health can be seen as a condition or qualitythe cause of human health and development. Indeed, during of the human organism in given conditions : genetic and •1•
  4. 4. environmental. Secondly, in a narrow sense, more useful for To understand as to what preventive medicine has come toworking purposes, health means : represent as a movement within medical theory and practice, itThere is no obvious evidence of diseases and that the person is is necessary to follow historically the application of the conceptfunctioning “normally”, i.e. conforming within normal limits of and its interaction with other movements. As said earlier,variations to the standards of health criteria, generally accepted preventive medicine, in its modern form, is not the same asfor one’s age, sex, community and geographic region and, the older discipline of public health, although the principles and techniques of prevention are also widely applied byThat various organs of the body are functioning adequately in public health professionals. Initially, preventive medicine wasthemselves and in relation to one another, which implies a kind identified with its most outstanding activity, i.e. contributingof equilibrium or homeostasis. to the control of communicable diseases. In fact, in its earlyMedicine years, preventive medicine was equated with infectious diseaseThe noted medical historian Henry Sigerist (9) defined medicine control. Subsequently, by applying specific measures, asas “Medicine, by providing health and preventing illness, demonstrated by the continuing emergence of “Epidemiology”endeavours to keep individuals adjusted to their environment (one of the most important tools of preventive medicine & publicas useful and contented members of society; or by restoring health), the preventability of non-communicable diseases washealth and rehabilitating the former patient, it endeavours to demonstrated as well, with health education and counsellingreadjust individuals to their environment. for behaviour change being added on to the armamentarium ofIt is clear from the above-mentioned, widely accepted definition, preventive medicine.that “Medicine” as a discipline, has two clear components - firstly Public Healththe “promotive and preventive” component, which is mainly the The perspective of public health is captured in statementspurview of preventive medicine; and the other, a “restorative contained in the report on “Higher Education for Public Health”and rehabilitative’ component, which is the main purview of the Milbank memorial commission (10). In public health,of curative medicine. However, there is no such sacrosanct problems are named within the context of the community asdividing line in practice, since very often, a clinician may also a whole rather than occurring in a series of individuals. Thisadopt ways and means of primary and secondary prevention, view leads to the establishment of priorities and permitswhile a preventive medicine practitioner may very often focus rational choices on the use of resources. From this view alsoon basic clinical care or rehabilitation. Finally, public health, as comes a commitment that is communal rather than personal,a discipline, keeps a focus on both the components, i.e. health one in favour of solving problems for the benefit of the healthpromotive / preventive as well as restorative / rehabilitative, of the population as a whole. Over the years, the unique featurebut distinguishes itself from curative or specific preventive of public health has been acknowledged to be “Organizedmedicine in two very special facets - that in public health, the Community Effort” and “Systematic Social Action” and thefocus is on the “Public” (i.e. a community or a population) and classical definition of public health, which has stood the test ofnot on any individual and that the approach utilizes “organised time, is the one forwarded by CEA Winslow (11) as :community efforts”, as we shall appreciate a little later. “The science and art of preventing disease, prolonging life andPreventive Medicine promoting physical health and efficiency through organizedPreventive Medicine is that branch of medicine which deals with community efforts for the sanitation of the environment, thepromoting health and preventing disease. The cardinal goal control of community infections, the education of the individualof preventive medicine is to avert the occurrence of disease. in principles of personal hygiene, the organization of medicalAchievement of this goal requires that actions be directed at and nursing services for the early diagnosis and preventivethe earliest stage of the natural history of disease, i.e. stage treatment of diseases and the development of social machineryof susceptibility, using the methods of health promotion and which will ensure to every individual, in the community, aspecific protection; and to some extent, methods of secondary standard of living adequate for maintenance of health”.prevention by early detection of disease when it may be Thus public health is best identified as a social movementotherwise not detected using usual methods of diagnosis, often concerned with protecting and promoting the collective health ofby screening followed by appropriate intervention. However, in the community. This is its origin and this is its accomplishment.a broader sense, preventive medicine refers to “limiting” the Thus, the province of public health is by no means limited toprogression of disease at any stage of its course. Thus, when prevention. While mostly public health activities are fundeda clinician, using the approach of curative medicine, diagnosis and regulated by the Governments (National or State), theand treats a patient of pulmonary tuberculosis, she is practicing work of voluntary health agencies is also very much partpreventive medicine too, since she is “preventing” the progress of public health activities since they represent an organizedof the disease from the mild / uncomplicated phase to one of community effort and systematic social action. In fact, evencomplications and more disability. Similarly, when we “treat” a small movement by a small village to purify their drinkinga patient of Colle’s fracture, by closed reduction and plaster water source or to stop alcohol drinking is also very much acast, we are actually limiting the progress of a disease to a public health activity. As has been very aptly stated by Mustardmore severe form which would have complications like mal- “A health problem becomes a public health responsibility if, orunion; thus we are practicing preventive medicine (preventing when, it is of such character or extent as to be amenable todisability). solution only through systematized social action” (12). •2•
  5. 5. Preventive Medicine versus Public Health a governmental commitment and out of governmental (public)The dividing line between preventive medicine and public finances, as is the policy in is actually a very thin, rather hazy one. Preventive Community Medicinemedicine is an overall science, public health is an approach As a professional movement, Community medicine (orwithin this science. When preventive medicine starts focusing Community Health) is the most recent of the three fields toon population groups rather than individuals and utilises the emerge in medical education and medical practice. As aapproach of ‘organised community efforts” it takes the shape discipline, it is defined as that branch of medicine, whichof public health. addresses certain selected aspects of health promotion,The other approach of using preventive medicine is the disease prevention, health restoration (by curative steps)“individualized” preventive medicine, for instance, immunising and rehabilitation of the former patients, in the community,an otherwise healthy child, or the “clinical” preventive medicine, usually, from an “Institutional Community Base” which iswhich can be very effectively practiced in clinical settings; for usually either an Academic Department in a medical collegeexample, a doctor who educates her ante-natal case about breast or through a curative centre. Community medicine, as anfeeding or a doctor who takes a pap smear from her patients approach, has borrowed heavily from the concepts, methodswho are attending a family planning clinic is actually practicing and approaches of its two elder sisters, viz. public health andindividualized or clinical preventive medicine, but, may be, preventive medicine.not public health. On the other hand when the government or Community medicine is one pathway for representing aneven a Non Governmental Organization (NGO) working with institution’s commitment to improving health of its immediatecommunity members in a village, organises a health education (or adopted) community - generally a medical college, hospitalprogram in breast feeding for expectant mothers, or organises or a clinical department serve as the base. The health task isa cervical cancer screening camp, the approach becomes that to define the health problems, propose solutions, maintainof public health. surveillance, evaluate progress and monitor the use ofSocial Medicine resources. The approaches employed range from tools ofThe concepts of social medicine were formulated by some very epidemiology to the social skills, necessary for involvementeminent physicians like Rudolph Virchow, Grotjahn and Rene with the community. Central to the approach of communitySand, besides others. The fact that man is a social animal, it medicine, whether in academia or in practice, is the promiseis apparent that any effort at preventing or curing the disease that the main factors that determine a community’s health areor making an assessment of the health problems has to take to be found within the community itself - in its social, culturalsocial factors into account. This is, in essence, the concept of or biological features, or in its environment - natural and mansocial medicine. Subsequently, the concepts of social medicine made.merged with preventive medicine, to form the specialty of An understanding of the ways in which these factors interactpreventive & social medicine (see later). to cause disease or promote health in different communities, is basic to the decisions to be made in the care and protection ofPreventive & Social Medicine the community (13). For these reasons, community medicineBeginning from somewhere around the mid twentieth century, must be concerned with and relate to, the community behaviourit was realized that the art and science of preventive disease and its environment and not solely restrict itself to the healthand promoting health should be taught as an independent services, which, very frequently, is otherwise the principalsubject in the curricula of medical schools. Till then, most interest of the Institutional unit responsible.of the medical colleges were conducting such training for As a professional movement, in USA, community medicinegraduate level students under the subject nomenclature first appeared when some medical schools began to establish“Hygiene” usually as a part of General Medicine curriculum. a new department (or rename an existing Dept of PreventiveIt was also realized that every human disease has deep rooted Medicine) and to charge it with functions of defining thesocial causes and not simply a result of an infectious agent. For health problems of a community (in the vicinity of theexample, everybody does not get infected with tubercle bacilli; college, or an adopted community) and to suggest solutions,and even out of those who get infected, only a small proportion maintain surveillance and monitor progress. Many hospitalsdevelop the actual disease. Who gets the infection and who gets also established department of community medicine to bringthe disease is actually decided by a wide array of social factors together responsibility for the professional direction andas poverty, ignorance, overcrowding, malnutrition and so on. coordination of a range of ambulatory programs in OPD andThe considered decision was that preventive medicine should emergency, personal health, outreach satellite elements andessentially combine the social aspects of health and disease other services. In UK, community medicine essentially includesin its theory, practice and teaching. This led to the birth of Epidemiology and Medical Administration and has been seenacademic departments and the specialty of Preventive & Social as a successor to public health, providing information andMedicine (PSM) or Social & Preventive Medicine (SPM). advise on the health status and the services to the communitySocialized Medicine and to the local Self Govt / community organizations, as well asSocialized Medicine is different form Social Medicine. It refers performing other planning and management functions. Thus,to the policy of providing complete medical care, preventive in UK, the community medicine specialist is trained to functionand curative, to all members of a society (usually a nation) as as Medical Officer of Health (MOH). •3•
  6. 6. Evolution of Contemporary Public Health Contemporary Views on the Definition, Role,From Shattuck and Chadwick in Mid-Nineteenth Principles, Core Activities and Components of PublicCentury to Twenty-First Century (14, 15) HealthIn the late nineteenth and early twentieth century, concern Definition : The Definition of Public health, as enunciated bywith control of epidemics was at the centre of medical and Winslow (11) and which has been presented earlier, though morepublic attention. Measures for protection of the community than 80 years old now, has stood the test of time and is verythrough “environmental health” appeared first and with the well accepted among the public health fraternity as the mostestablishment of effective sanitary services, the modern era standard definition. Another definition given by the Institute ofof public health was born. Later, towards end of nineteenth Medicine (USA) also echoes the same ethos : “Public Health is acentury, microbiology expanded greatly and laid down new and mission for the fulfillment of society’s interest in assuring thescientific basis of infectious disease control. When it become conditions in which people can be healthy, through organisedclear that an “organized effort” to apply these sanitary and community efforts aimed at the prevention of disease and thebacteriologic techniques was needed, the responsibility of promotion of health, using activities undertaken within thegovernmental health departments, to control the communicable formal structure of government as well as the associated effortsdiseases, was given the status of law; and since treatment of of private and voluntary organizations and individuals” (16).infected individuals was also a part of control of infectious Role of Public Health (16) : As per international consensus,diseases, this also become a responsibility of public health. Later the role of public health is to contribute to the health of thepublic health responsibility was further extended for organized public (community) through :maternal and child health services, thus extending public Assessment of Health Status & Health Needs : For makingresponsibility into the realm of personal care of individuals. As assessments of health status and health needs and to reacha result, organized “programs” for prevention (usually public a “community diagnosis”, with the ultimate objective offunded but often by voluntary, non govt. organizations) become formulating health policies and planning appropriate healthmore visibly identified. services, public health specialists draw heavily from theIn the first half of the 20th century, personal preventive “quantitative sciences” (Epidemiology, Research Methodology,services in large numbers began to be publicly financed, while Bio-statistics, Information Technology); from “Environmentalthe personal curative services, for the most part, remained Sciences”; from “Socio-Behavioural & Communicationprivately supported. As a result the personal health services Sciences”; and, from “Bio-Medical Sciences”.become compartmentalized into two different medical practice Development of Health Policies : For this purpose the publicsettings - one largely preventive and the other largely curative. health specialist will need a good knowledge of QuantitativeHowever, later on, as the concept of “comprehensive health Sciences; Managerial Sciences; and of Socio-Behavioural &care” came in, the traditional dichotomy between preventive Communication Sciences.and curative medicine become less and less differentiable. Assurance of the Availability and Quality of Health Services:One way of coping with the compartmentalization of activities To fulfill this role, sound knowledge of Basic Clinical Skills,into the two practice settings (preventive & curative) is to Managerial Sciences, Bio-Medical Sciences and Quantitativerationalize their inter-relationships. For example, the concept Sciences would be an essential requirement.of prevention has been, in recent times, extended into curative In fact, the present text-book has been organized addressing,settings in the form of “secondary prevention”, as one form of in a section-wise manner, the various core-competencies asresponse to the rising frequency of chronic, non-communicable enlisted above. These major sciences required for the practicediseases and diseases of special groups (mothers, children, of public health can be grouped into five major core competencyold people and industrial workers). Under this new strategy, areas, viz. Quantitative Sciences, Environmental Sciences,clinicians are being urged to think more regularly about Socio-Behavioural and Communication Sciences, Biologicalpreventive management in diseases and to incorporate more Sciences and Managerial Sciences. The details of these coreof a preventive outlook in their daily practice. Similarly, areas are given in Table - 1.public health physicians are being invited to move fromtheir preoccupation with primary prevention, to undertake Core Principles Underlying Public health Practice:administrative involvement in health care systems. By doing Contemporary thinking indicates that the principlesso, they could relate to the total range of health care and underpinning the concepts of public health are as follows andtake part in the planning, operation and evaluation of any the public health specialist must develop the mental attitude toor all of the health services. In fact, according to one of the adopt these core principles in her activities (17) :contemporary views, “Medical Care Administration” has been ●● The emphasis on collective responsibility for health.advocated as a legitimate concern of public health authorities. ●● An envisaged major role of the state in protecting andWhile mostly public health activities are funded and regulated promoting the public’s the Govt. (National or State) the work of voluntary health ●● A focus on whole populations and not on individuals.agencies is also very much part of public health activities since ●● An emphasis on prevention, especially primary prevention,they represent an organized community effort and systematic while not losing track of the importance of curativesocial action. medicine also. •4•
  7. 7. ●● Readiness to undertake partnership with populations Table - 1 : Core-Competency Areas in Public Health being served. Training & Practice The “Dozen” Core Activities of Public Health : In 1995, the (a) Quantitative and Analytical Sciences US Health and Human Services department identified ten core ●● General Epidemiology activities of public health (18). In our national context, we can ●● Field Epidemiology, including outbreak investigations think of the “One Dozen” core activities of public health, as and public health surveillance systems follows : ●● Bio-statistics including statistical software 1) Protecting the environment, food and water. ●● Health Research Methodology 2) Promoting healthy behaviour through information, ●● Database Management and other core issues of education and communication. Information Technology 3) Assessing needs, making community diagnosis and (b) Environmental Sciences monitoring the health status of the population/ community being served. ●● Water and Food Safety 4) Leading to the development of sound health policy and ●● Sanitation and Disposal of Wastes planning. ●● Environmental heat, cold & altitude and related aspects 5) Health programme management and management of other of shelter & clothing medical & health care systems (health care system includes ●● Air, Soil and Noise Pollution the triad of personal medical care, public health care and ●● Nuclear & Chemical Pollution other inter-sectoral initiatives related to health). (c) Socio-Behavioural & Communication Sciences 6) Preventing and investigating epidemics and maintaining ●● Sociology in Health surveillance on important diseases, to provide early ●● Life Style & diseases of the lifestyle warning. ●● Health Education, Information, Education & 7) Promoting the health and efficiency of the “workers” and Communication (IEC) protecting the “work-environment”. 8) Effectively responding to disasters. (d) Biological Sciences 9) Mobilizing community action. ●● Clinical Sciences (basic diagnostics and therapeutics 10) Research to develop new insights and innovative solutions for common and important health problems in the for relevant community health problems. Community) 11) Reaching out to link the health services with the high ●● Microbiology & Pathology risk, disadvantaged and hard to reach people (socio- ●● Infectious and Non-Communicable Diseases : economically weaker sections, hilly, tribal and inaccessible Epidemiology, prevention and Control areas), or those requiring special attention (women, ●● Entomology children and old people). (e) Managerial Sciences 12) Assuring the availability, accessibility, quality and accountability of medical care. ●● General Principles of Management & application in Health care Bridging the Gap between Theory and Practice in ●● Health policies & programmes, including policy / Public Health and Community Medicine programme management A very peculiar situation which all specialists in public health ●● Legal issues in Health care and community medicine realize after just a few years of ●● Health systems and Organization of health care delivery practice, is the wide gap between “theory” and actual “practice” at various levels in this specialty. Such gaps occur in all other medical specialties ●● Personnel, Financial and Equipment Management too, but only to a limited extent - a patient of typhoid or one ●● Management of Hospitals & other Health Care Facilities with ante-partum haemorrhage will show variations as regards ●● Medical Care Administration at Primary, Secondary & clinical presentation and response to treatment when compared Tertiary level to what is written in the standard textbooks, but only to a ●● Management of Health Care for Special Groups (Women, limited, understandable extent. In public health practice, the Children, Workers, old people, the “challenged” and the practitioner is faced, everyday, with challenging situations, for socio-economically disadvantaged) addressing which she has to work out innovative solutions, ●● Health Care Management during Disasters which may not be at all described in her standard textbooks (in fact, that is why it is difficult to have a “standard textbook” in●● A concern for underlying socio-economic determinants of public health; one could only have guidelines!). The reason is health and disease as well as more proximal determinants, that in community medicine and public health, we do not deal such as health care. with a patient; we rather deal with human groups, who are●● A multi-disciplinary basis; the readiness to work, in a apparently healthy (at least that is the way they feel themselves team, with different and diverging disciplines concerned to be). Human groups or communities have their own attitudes with human health and development. and practices and their own diverse ways of assessing and●● Attitude to incorporate qualitative and quantitative responding to situations. methods, as appropriate, in the area of work. For the aforesaid reasons, the author would, based on own •5•
  8. 8. experience and the shared experience with colleagues, like to about their health problems and make assessment of theirnarrate, certain “rules of the game’, which are otherwise not behaviours, beliefs, lifestyle and the environment they live in.formally written down in any textbook. It is felt that putting 5. Develop “Multi - Disciplinary Team” approach : Alwaysthese guiding principles into day to day practice may help remember that in public health, you have to build an effectivebridging the gap between theory and practice, thereby deriving team, comprising of people from various disciplines - Statisticians,more satisfaction out of our specialty work. A dozen of such Clinicians, Social Scientists, Entomologists, Pathologists, Civilguiding principles are as follows : Engineers, Management experts, Administrators, Politicians1. Learn how to take insults, be tenacious : Remember that and so on. No public health specialist can be successful bypublic health / community medicine with its focus on prevention, working in isolation. Learn how to form an effective team;is more abstract than curative medicine and its achievements have respect for others, listen to their advice and take decisionsare therefore more difficult to recognize. The Doctor who cures in consultation with them after logical reasoning and not bysuch a person has achieved a real, recognizable benefit and arguing or bulldozing. In fact, be proactive in seeking out alliesthe patient is grateful; public health cannot point to the people from these various specialties / walks of life.who have been spared illness by its efforts. Public health and 6. Always prepare very well before you meet people :preventive medicine lead to silent, unrecognized victories. Whenever you go to attend a conference, be it of administratorsThis “silence” accounts in large parts, for the relative lack of and specialists from allied specialties, or else a focus groupattention paid to public health by decision makers and the discussion with school - teachers, make sure to always readgeneral public (in comparison to the attention paid to medical the agenda and its details very well. Apply your thought to thecare). issues under discussion, think what do you want to achieveSo, remember, that while Public health may not be as glamorous and how you will be best placed to do so, with those present.a specialty as Cardiac Surgery or Imaging, it has tremendous 7. Focus on “long term” but take action on “short term”potential to improve the quality of life of innumerable human also : The objectives of public health (whether through anbeings - to give you a proof, the major improvements in health immunization program or purification of community waterand quality of human life during the last one century have supply, etc.) are achieved over the longer time period of decadesactually come from clean food and water, sanitary housing and or generations. However, Governments are generally reluctant toimmunization rather than all the other “glamorous” medical think further ahead of the 5 year term of parliament / assembly.specialties put together. Despite this, preventive medicine and They would, naturally, like to demonstrate some results withinpublic health is often at the receiving end of insults as “Sewer the limited span of a couple of years. Hence, in public healthdrain doctors” “insect catchers” or “people who could never practice, while gaining support for achieving the long termmake it to the clinical world”. You have to learn how to bear goals should be definitely an objective, it is equally essential towith such humiliations, but do not lose heart - be tenacious, have some very readily identifiable strategies to demonstratekeep moving forward - you have indeed selected the most progress towards these long term goals, in a shorter period ofhumane specialty. time - the so called strategy of “Early Victories”.2. Stick to the facts - preferably based on quantitative 8. Understand the “Politics” : Very often we find public healthevidence : Public health, with its very important tools of specialists talking about ways of influencing “Policy Makers”.epidemiology and statistics, is an evidence based specialty This means getting to know your chief administrative bossand is dependant on collecting, analyzing and interpreting the (and other influential people) and how he or she works. Whendata in a valid manner and making use of good quantitative you are, as a public health management manager, affronted toand qualitative evidence. Good public health practitioners a one of senior politicians or bureaucrat, the first things youshould collect good knowledge about topics they are dealing should do is to set to know what makes him or her “tick” andwith, whether it is the incidence of ARI among children in their do things in a way that merges with his / her line of thinking.area of jurisdiction or it is concerning the amount of risk that Public health specialists should also keep themselves welltobacco carries for IHD. Good amount of reading into latest aware of the “political climate” - not only international andjournals, reports or text books and discussion with experts is a national but, also the “local” politics and even the politicalmust for public health practitioners. climate in their own office. It is essential, in public health, to3. Develop the art of communicating : Remember that unless have good political antennae. Moreover, in any organization or“data” are turned into “stories” which are understood by all, office, it is essential to understand as to who wields the powerpeople would not show concern for your reasoning. Having - this may not only be the chief executive, but may be somecommand on communication skills, both verbal and written, lower level staff officer also. It is also very paying to have goodis an art which is a compulsory requirement for public health relationships with colleagues.practitioners and this art should be developed very diligently 9. Don’t take on too much : Failure to deliver is one of theand methodically. biggest potential risks for public health and you should4. Walk well and talk well : A successful public health remember that one important reason for landing in this pitfall isspecialist is one who changes shoes every month or two, since when you take on too many jobs, well beyond your capabilities.constant walking, seeing for herself and making assessments of You should learn how to say “No” to tasks which you feel areenvironment and the community’s conditions, tears off the shoe getting on too much; or else, if it is something that has to be- sole very fast. This is the typical shoe - leather epidemiology. done, then decide what is going to be dropped off your agenda.So keep moving in your area, talk to the community members •6•
  9. 9. Next, once you take on a job, then keep track of its progress. preventing illness, endeavours to keep individuals adjusted to10. Develop Your Staff : A clinician may still do well without their environment as useful and contented members of society;improving his staff and without delegating; conversely, in public or by restoring health and rehabilitating the former patient,health practice you must constantly endeavour to develop your it endeavours to readjust individuals to their environment”.staff and subordinates as regards their technical and managerial Preventive Medicine is that branch of medicine which dealscompetence. Secondly, analyze their capabilities and learn how with promoting health and preventing disease. The cardinalto delegate responsibilities / tasks to your subordinates. If you goal of preventive medicine is to avert the occurrence oftry to do everything yourself, in public health practice, you will disease. The field of Epidemiology has emerged as one of theget bogged down and become inefficient pretty soon. most important tools in preventive medicine & public health. CEA Winslow gave the most comprehensive & widely accepted11. Always Know of Specialists who can do the Jobs : The definition for public health which states as “The science and artwide activity of public health inevitably means that you will of preventing disease, prolonging life and promoting physicalnot be able to retain all the necessary skills at any one time, health and efficiency through organized community efforts forthough you may have been trained to some extent in all these the sanitation of the environment, the control of communitydisciplines (as entomology, epidemiology, statistics, database infections, the education of the individual in principles ofmanagement, etc.). Therefore, maintaining networks with personal hygiene, the organization of medical and nursingothers who have the skills & expertise in that area, is vital. services for the early diagnosis and preventive treatment of12. Always Be There : Though stated in the last, this twelfth diseases and the development of social machinery which willgolden principle is one of the most important. Remember that ensure to every individual, in the community, a standard ofthe world is run by people who are physically there at the place living adequate for maintenance of health”. The two uniqueof action; the first rule of politics is to “be there”. It is surprising feature of public health are acknowledged as “Organizedhow scant attention is paid to this very simple dictum. So, Community Effort” and “Systematic Social Action”. Preventivefor being a successful public health specialist, never miss a Medicine is a branch of medicine which deals with promotingmeeting, a workshop, any function, a sports meet or even any health and preventing disease. When preventive medicinestreet play to which you have been invited. starts focusing on population groups rather than individualsAnd, finally, keep the highest regards for your specialty - it is and utilises the approach of “organised community efforts” itthe biggest asset you have in the changing fortunes of time; takes the shape of public health. The integration of the socialKeep perseverance and faith alive, for, despite all it’s drudgery aspects of health and disease in theory, practice and teachingand sham, it is still a beautiful world ---------. led to the birth of Preventive & Social Medicine (PSM) or Social & Preventive Medicine (SPM). Community Medicine is aSummary branch of medicine, which addresses certain selected aspectsThe last two decades of the 20th century saw a renewal of of health promotion, disease prevention, health restoration (bythe world population’s interest in public health, in disease curative steps) and rehabilitation of the former patients, in theprevention, communicable and chronic disease control, health community, usually, from an “Institutional Community Base”protection and health promotion. The two reports in mid- which is usually either an Academic Department in a medicalnineteenth century by Edwin Chadwick in UK & Lemuel Shattuck college or through a curative USA initiated the genesis of public health & preventive Public health plays a very important role in contributing tomedicine. During the 20th century, many lives have been saved the health of the public (community) through assessment ofand diseases prevented by simple public health measures as Health Status & Health Needs, development of Health Policies,safe water supply, sanitary excreta disposal, vaccination and assurance of the availability and quality of Health Services.insect-vector-control measures. Major sciences required for the practice of public health can beWidely used definition of health by WHO states that “Health is grouped into five major core competency areas, viz. Quantitativea state of complete physical, mental and social well being and Sciences, Environmental Sciences, Socio-Behavioural andnot merely the absence of disease or infirmity. This definition Communication Sciences, Biological Sciences and Managerialis commonly seen as the statement of an “ideal” towards which Sciences.nations should aspire. “Operational” definition of health, one Core Activities of Public Health include protecting thedrawn from the above “ideal” definition, has been forwarded, environment, food and water, promoting healthy behaviourby a technical study group of WHO. This concept of health is through IEC, assessing needs, making community diagnosis andviewed as being of two orders - first, in a broad sense, health monitoring the health status of the community being served,can be seen as a condition or quality of the human organism development of sound health policy and planning, healthin given conditions : Genetic and environmental. Secondly, programme management and management of other medical &in a narrow sense, more useful for working purposes which health care systems, preventing and investigating epidemicsincludes no obvious evidence of diseases and that the person and maintaining surveillance on important diseases, to provideis functioning “normally” & various organs of the body are early warning, promoting the health and efficiency of thefunctioning adequately in themselves and in relation to one “workers” and protecting the “work-environment”, effectivelyanother. responding to disasters, mobilizing community action, researchA widely accepted definition of medicine by Henry Sigerist to develop new insights and innovative solutions for relevantdefines medicine as “Medicine, by providing health and community health problems, reaching out to link the health services with the high risk, disadvantaged and hard to reach •7•
  10. 10. people, or those requiring special attention, assuring the (3) Condition or quality of the human organism in givenavailability, accessibility, quality and accountability of medical conditions : genetic and environmental; Within normal limits ofcare. variations to the standards of health criteria; various organs of the body in a state of equilibrium or homeostasis (4) OrganizedStudy Exercises Community Effort; Systematic Social Action (5) OrganisedShort Notes : (1) Definition of health (2) Definition of public community efforts; Public health (6) Preventive (3) Community Medicine - definition and scope (4) Core Match the Following : 1-d; 2-c; 3-e; 4-b; 5-a.activities of public healthMCQs & Exercises References 1. Richardson, BW. The health of nations : a review of the works of EdwinFill in the Blanks Chadwick, vol 2, London 1887; Longmans, Green & Co.1. Movement - now known as public health were initiated in 2. Shattuck, L. Report of the sanitary commission of Massachusetts - 1850. (Dutton & Westworth, state Printers, Boston, 1850). Cambridge, 1948, nineteen century by -------- &----------- in their reports on Harvard university Press. sanitary conditions of the labouring population in Great 3. US Public health service. For a healthy nation : returns on investments in Britain & sanitary commission of Massachusetts. public health.washington, DC : US Government Printing Office 1994 : p. 42.2. Health is a state of complete ---------, ---------- and ------- 4. Bunker JP Improving Health : Measuring effects of medical care. Milbank . quarterly 1994; 72 : 225 - 58. well being and not merely the absence of ------------ or -----. 5. Soanes C. Oxford Dictionary. Oxford University press, Oxford 9th ed, 2001. This was the definition given by ----------------. 6. Engel GL. The need for a new medical model. A challenge for biomedicine.3. “Operational” definition of health view’s health as being Science 1977; 196 : page129. ------------------ in broader sense & -----------, ----------- in 7. World Health Organization. The constitution of World Health Organization. WHO Chron 1947; 1 : page29. narrower sense. 8. World Health Organization. Measuring the levels of health : Report of a4. Two unique features of public health are ---------------- and study Group. WHO TRS No 137, 1957. ----------------. 9. Sigerist HE. A history of medicine, Volume I : Preventive and Archaic Medicine. New York; Oxford University Press, 1951.5. When preventive medicine starts focusing on population 10. Milbank memorial Fund Commission Report, CG Sheps, Chairman. Human groups rather than individuals and utilises the approach Education & Public Health, New York : Prodist, 1976. of ------------- it takes the shape of----------. 11. Winslow C-E,A. The untilled fields of public health, Science 1920; 51 : page6. ---------- is the branch of medicine which deals with 23. 12. Mustard HS, Stebbins EC. An introduction to public health. New York, promoting health and preventing disease. Macmillan. 4th edition 1959.Match the Following 13. Kark SL, Cobb S. From medicine in the community to community medicine. JAMA 1974; 228 : page 228.1. CEA Winslow a. Sanitary commission of 14. Horton R. the new public health of risk and radical engagement. Lancet Massachusetts 1998; 352 : 251 - 2. 15. Hamlin C, Sheard S. Revolutions in Public Health : 1848 and 1998 ? BMJ2. Henry Sigerist b Social medicine 1998; 317 : 587 - 91.3. Rudolph Virchow c. Definition of Medicine 16. Institute of Medicine (USA). The Future of Public health. Report of Committee for the study of the future of public health. Washington, DC.4. Grotjahn d. Definition of Public health National Academy press, 1988 : 40 - 42. (Available at : http : //fermat.nap. edu/catalog/1091html (accessed in 2006).5. Lemuel Shattuck e. Virchows triad 17. Beoglehole R, Bonita R. Public Health at the cross-roads. CambridgeAnswers : University press, Cambridge U.K., 1997. 18. U.S. Health and Human Services, Public Health Service. For a healthyFill in the Blanks : (1) Edwin Chadwick; Lemuel Shattuck nation : returns on investment in public health. U.S. Govt. Printing office,(2) Physical; Mental ; Social; Disease; Infirmity; WHO Washington DC, 1995. healthy living and pursued regimens of exercise and hygiene 2 History of Public Health such as those prescribed by Hippocrates in his Regimen and Regimen in Acute Diseases (4th century BC). Patients visiting the temples of the god of healing, Aesculapius, were encouraged Leo S. Vaz to take part in exercise, but the temples were, again, not part of a public health system. There was some development ofDuring the ancient Egyptian period developments such as public health by the Minoans, a Mediterranean civilizationtoilets and bathing were introduced, but this was on a private that flourished on Crete about 3000-1050 BC. The Minoanslevel. While Egyptian religious beliefs encouraged washing the built baths and constructed channels to supply clean waterbody, thereby improving the health of the population, this was and remove waste. However, these facilities were lost whennot part of a public health programme. The Greeks encouraged the Minoan civilization collapsed and their palaces and towns •8•
  11. 11. were destroyed by natural disasters and invading Greek forces. During the Middle Ages (5th-15th centuries) in Europe, publicAqueducts (bridges carrying water) were also constructed; one health systems collapsed and became virtually non-existent,of the first great aqueducts was built in 691 BC to carry water particularly during the period known as the Dark Ages (aroundfor 80km to Ninevah, capital of the ancient Assyrian Empire. 500-1000 AD). The towns and cities of the Romans were oftenHowever, the scale of the public health system introduced by abandoned and the aqueducts, sewers and baths were allowedthe Roman Empire from around 300 BC was without precedent to fall into disrepair. Medieval governments and wealthyin the Western world. people in society no longer felt the responsibility or need toAncient India and Public Health provide public health. Money was not spent on providing fresh, clean water or removing waste, but on more pressingAncient Indian thoughts, philosophy developed on concepts of concerns, such as the provision of armies and defences forspirituality. Ayurveda is the ancient science of life. It lays down the almost continuous wars that raged throughout the period.the principles of management in health and disease and the Various diseases (leprosy, consumption, typhoid fever and thecode of conduct for the physician. Charaka has described the black death) fatally affected approximately one-third of theobjective of medicine as two fold; preservation of good health population living in middle and southern Europe. In the Middleand combating disease. Ayurveda emphasised the need for Ages, commerce and industry developed which were based onhealthy lifestyle, including cleanliness and purity, good diet, economic theory involving exchange of goods and services.proper behaviour and mental and physical discipline. Purity Through the accumulation of wealth, individuals and nationsand cleanliness were to be observed in everything : jalasuddi became powerful. Because of such affluence, concern developed(pure water), aharasuddi (clean food), dehasuddi (clean body), for labour as it related to productivity. manasuddi (pure mind) and desasuddi (clean environment). Streets were often used as dumping grounds for slaughterhouseAyurveda calls upon the physician to treat the patient as a whole: waste or the contents of chamber pots from people’s houses.‘Dividho jayate vyadih, Sariro manasasthatha, Parasparanz Action was only taken during outbreaks of disease such as thetavorjanma, Nirdvadvam nopalahhyate’. Diseases occur both Black Death, an epidemic of bubonic plague that swept acrossphysically and mentally and even though each part might Europe in the mid-14th century, killing between one-third andbe dominant, they cannot be compartmentalized. Ayurveda half of the population. When the plague arrived in England intreats man as a whole body, mind and what is beyond mind. 1348, Edward III ordered the lord mayor of London to clean upThe earliest protagonists of Indian Medicine, such as Atreya, the streets of the capital and keep animals and slaughterhousesKashyapa, Bhela, Charaka and Susruta have based their out of the city. Public toilets were to be introduced andwritings on the foundations of spiritual philosophy and ethics. the dumping of waste in the streets was forbidden. TheCharaka Samhita prescribes an elaborate code of conduct. improvements continued until the end of the 14th century, butThe ruins of ancient civilizations like Mohenjadaro and the measures were often poorly enforced and had little effectHarrappa show intricate water and sullage disposal systems. on the overcrowding and lack of cleanliness that was rife inIt can hence be assumed that sanitation played a major part in the larger towns and cities. Few hospitals existed and doctorsplanning of these cities. were far too expensive for the poor to consult, so ill health andGreeco-Roman Era disease were unchecked and spread rapidly.This period focused on personal hygiene. Governmental public 18th-19th Centuries (Europe)health practices were effected to augment the prevailing This was the period of the industrial revolution and cholerareligious attitude. Medical care hospitals, staffed with public epidemics. The industrial revolution brought about the need forphysicians and programs in environmental sanitation (water increased manpower and massive use of labouring classes. Thesupply and sewage) were developed. These measures which life expectancy rate based on social class was : gentry, 35 years;placed a high priority on a clean mind and body were developed tradesmen, 22 years; and labourers, 15 years. Approximatelyfor the upper classes. The Romans were able to implement one-half of the children of the working classes died before agepublic health measures as they had an organized, centralized of five.government and the money to pay for the work. Such a vast William Farr, the keeper of abstracts at the Registrar Generalsystem of public health was unprecedented in history and Office in 1836 was convinced that mortality increased withmade the Romans a much healthier people. The Romans did density of population. From 1839 William Farr collectednot know about bacteria and the true causes of disease, but statistics from parish registers on births and deaths. He wasthey observed that swamps caused illness and that a lack of able to show the impact of poor living conditions on lifefresh water was damaging to health. By the end of the Roman expectancy and the differences between different areas. TheEmpire in AD 476, the Roman public health system was more Victorian middle class believed that the overcrowding resultedadvanced than any system of public health would be in Europe in immorality, drunkenness, crime, incest and destroyed thefor the next 1,400 years or so. sanctity of homes. This resulted in moralistic theories beingMiddle Ages projected all over Britain & Europe as a cure of most evilsThis is considered as a period identified as an era of paganism, including disease.barbarism and anti-intellectualism. When Christianity became The poor engaged in agriculture went through a series of badthe official religion of the Roman Empire, the poor and afflicted harvests at the end of the eighteenth century and by 1795 thewere given status and recognition. Society was given an farmers had fewer & fewer resources to pay their labourers.obligatory responsibility for care and treatment of the sick. An allowance system was then started and administrated •9•
  12. 12. through the Poor Law. A study of Poverty was carried out by vaccination was started by John Gibbs which ultimatelytwo assistants of Central Poor Law Commission an economist culminated in its modification in 1907.and lawyer Nassau Senior and upwardly mobile lawyer Edwin Public Health in the United StatesChadwick. They concluded that the allowance system was athreat to the free market economy. The Poor Law Amendment In the 17th - 18th Centuries in Colonial America, life1834 which Chadwick wrote deprived the paupers of his liberty expectancy was less than in Central Europe. Towns and citiesand put them into workhouses. were generally unsanitary, contagious diseases were rampant and most physicians were self-designated and itinerant. InThe cholera Epidemic of 1832 highlighted the problem of America the first colonist had found healthy land, clean waterdisease. In 1837 Chadwick appointed doctors to investigate and fertile soil. However newer arrivals brought in scurvy,the London districts with high typhus mortality. The report smallpox, cholera, measles, typhoid diphtheria and influenza.highlighted the squalor of the inhabitants and the insanitary Small pox and measles contributed in large part to mortality.conditions. Chadwick compiled a survey of “Sanitary condition In the eighteenth century quarantine laws were passed in allof labouring classes of great Briton” in 1842 in which he major towns and pest-houses built for immigrants arriving onrecommended the “Sanitary Idea” with creation of a public infected authority to provide drainage, potable water, sanitation,regulation of buildings etc. He believed in the ‘miasmatic’ During the civil war a large number of soldiers died of Typhoid,theory of disease origin where gaseous contamination of Malaria, camp Diarrhoea and camp Measles. However, whereveratmosphere due to putrefaction of organic matter was the the sanitary commission improved sanitary conditions, diseasecause of disease. rates were found to be lower. Due to the industrial revolution cities grew and there was increase in number of disease. Due toThe first British Public health Act was passed in 1848 creating a dedicated band of reformers, the Metropolitan Health Bill ofa General Body of health with Southwood Smith as its medical 1866 was passed. In 1879 a large yellow fever epidemic sweptadvisor and Chadwick its only salaried member. The city of Mississippi and New Orleans, resulting in the creation of theLondon also had its own private Sewers Act 1848. Internal National Board of Health.conflicts in the Metropolitan Sewers Commission resulted inremoval of Chadwick in 1849. The Lemuel Shattuck Report encouraged social reform, including documentation of disease conditions and collection of vitalA shift from “Sanitary idea” to medical managed took place when statistics. Some pertinent recommendations of the ShattuckChadwick was succeeded as Britain’s chief health administrator Report were establishment of sanitary inspection system,by Dr John Simon. The new concept was of “State Medicine” He the collection and analysis of vital statistics, the promotionhad been credited to having laid the foundation of subsequent of health care, establishment of regulations to expose andBritish health policy. He followed a comprehensive approach eliminate quackery. Port cities such as Boston, Baltimore,to disease prevention and set up investigations into a wide New York and their respective states sought ordinances andrange of issues from regulation of food contamination & drug legislation to reduce mortality, establish medical services foradulteration to hygiene standards of environmental planning. seamen and raise the professional status of physicians.Simon’s most significant legislation was the Sanitary Act 1866.In 1856 Dr Henry Rumsey published a series of “Essays on state Sanitary TheoryMedicine”. He claimed that medical prevention would cover a The theory of miasma, which said that disease is due to causesbroad range of causes of disease resulting in their elimination. contained in bad air including the cosmic radiations, foundIn 1875 the Public Health Act was codified including all much support during the 18th and 19th century. It made sense toexisting sanitary legislation. The prevailing social conditions the English Sanitary reformers of the mid-nineteenth England resulted in an illustrative national survey, known Miasma explained why cholera and other diseases wereas the Edwin Chadwick Report, which focused on the health of epidemic in places where the water was un-drained and verythe labouring classes. The Chadwick Report affected sweeping foul-smelling. The theory led to improvements in the sanitationreforms, such as the establishment of a National Board of systems, which led to decreased episodes of cholera, whichHealth, advances in environmental sanitation and hygiene, helped to support the theory. Even though the miasmatic theorynew legislation regulating factory management; child labour has been dis-proven by the knowledge of viruses and bacteria,and welfare and care for the aged and mentally ill.  it made the connection between dirtiness and diseases. ThisIn 1864 the first contagious Disease Acts was passed which caused public health reforms and encouraged cleanliness, evenprovided for compulsory examination of women believed to be though some doctors still did not wash their hands between“Common prostitutes” who were to be locked up for up to one patients. They believed that the miasmata were only airborneyear without right to habeas corpus if they were diagnosed to and would not be stuck on the doctors’ hands.have sexually transmitted disease. The Act was approved by Chadwick has generally been considered to be the person whoa large number of people including John Simon. The Act was defined prevention of disease in “ Sanitary” terms. Howeverrepealed in 1886. Edmund Parkes, the first British Professor of hygiene whoFree vaccination were made available through the Poor Law was appointed to the Army Medical School at Netley believedMedical Services in 1840. In 1853 vaccination was made that future of prevention lay in discovery of specific causes ofcompulsory for all children with the first year of life. In individual diseases.1867 the new Vaccination Act imposed penalties on parents A shift in public health took place during the Edwardiannot vaccinating their children. A drive against compulsory period when individuals began to be categorized into “Risk • 10 •
  13. 13. populations”. These were on the basis of analysis of disease organisms, it was concluded that water sanitary hazards atby Edmund Parkes. Soon thereafter came the germ theory industrial sites were generally remote with the exception ofwhich was based on the concept that specific microbes caused anthrax from tanneries and wool scouring facilities.specific diseases. Developments in Bacteriology in 1880’s were Current Public Healthembraced by the preventive profession. A model was developedin which one agent was related to one disease (Robert Koch). Classical infectious disease rates have declined while increasedThis is discussed in subsequent chapters. rates of so-called modern diseases (heart disease, cancer and immune deficiency diseases) are now being observedContemporary (19th and Early 20th Centuries) Public in epidemic proportions throughout the world. ClassicalHealth public health organizations and systems are now in a stateDuring the 19th Century and the first half of the 20th century, of flux because these structures were erected for classicalthe perception of public health was limited to prevention of communicable disease control. New problem-solving systemscommunicable diseases through environmental sanitation. are needed in areas such as health care financing, medical careFor example, a dramatic increase in industrialization in the for the aged, environmental health protection and health carelate 19th century, coupled with urbanization, had profound planning and administration.effects on urban water supplies. There was pollution fromhuman wastes from homes and the workplace disposed in the Founders of Modern Public Health, Communitywaterways. Effluents containing organic and inorganic toxic Medicine & Preventive Medicineand non-toxic material were dumped into the same waterways. Edward Jenner(1749-1823)During this time medical theories were limited to bacteriological Edward Jenner was born on May 17, 1749 in the small villageparadigms. in Gloucestershire. He had always beenIn 1898 when US sent troops into Cuba they lost 968 men fascinated by the rural old wives tale thatin battle and 5438 due to infectious diseases. When yellow milkmaids could not get smallpox. Hefever threatened troops in Cuba in 1900 an army commission believed that there was a connection betweenunder Walter Reed confirmed that the disease was transmitted the fact that milkmaids only got a weakby mosquito and eliminated the disease from Havana. The version of smallpox - the non-life threateningUS Army in Philippines had to battle with malaria, dengue, cowpox - but did not get smallpox itself.dysentery and beriberi to continue to remain in the region. Jenner decided to try out a theory he hadThe French attempt to build a canal across Panama was developed. Jenner was given the opportunityabandoned due to disease. The American attempt succeeded on the 14 May 1796, when a young milkmaiddue to an intensive campaign against mosquitoes and hence called Sarah Nelmes came to see him with sores on her handsreduction of yellow fever and malaria so as to prevent malaria like blisters. He took some pus from cowpox blisters found onin America troops. During World war II the Public Health service the hand of Sarah. She had milked a cow called Blossom andestablished the control of Malaria in war areas. After the war had developed the tell-tale blisters. Jenner ‘injected’ some ofthe organisation was converted into the Centres for Disease the pus into a young boy, James Phipps. This process heControl and Prevention. repeated over a number of days gradually increasing theIn 1907 preventive medicine practitioners and town planners amount of pus he put into the boy. He then deliberately injectedgot together to bring about housing reforms. Simultaneously Phipps with smallpox. James became ill but after a few dayslegislations were passed for free school meals, medical inspection made a full recovery with no side effects. Jenner found a greatof school children and antenatal care. These concerns were deal of scepticism to his ideas and was subject to much ridicule.clubbed by society into “Endowment of motherhood” movement However, what he had discovered could not be denied andwhich included targeting of malnutrition and breaking habits eventually his discovery had to be accepted - a discovery thatof inefficient and unhygienic motherhood. A great emphasis was to eventually change the world. So successful was Jenner’swas placed on health education. It was emphasised that infant discovery, that in 1840 the government of the day banned anymorality was not a “Weeding Out” process of eugenic value as other treatment for smallpox other than Jenner’s. Jenner died inwas earlier considered, but a preventable wastage of child life. Berkeley on January 26, 1823 aged 74.The word vaccinationNewsholm in 1910 introduced the concept of “Causal attack” comes from the Latin ‘vacca’ which means cow - in honour ofupon disease after redefining the environment from a “Social the part played by Blossom and Sarah in Jenner’s research.Standpoint”. However, from the point of Jenner’s demonstrations, it took the humanity almost two centuries to conquer small pox - In 1980,In Germany, Pettenkofer first calculated the financial returns the World Health Organisation declared that smallpox wason public health investments to prove the value of sanitary extinct throughout the world.improvement in reducing death from typhoid. John Snow (1813 - 1858)Bacteriological analysis was used to determine the presence ofcoliform bacteria in municipal water supplies. Since coliform Snow was a British physician and also one of the founderbacteria are present in great numbers in humans and animals fathers of the discipline of anaesthesiology, is also consideredbut are not typical water organisms, their presence served as an one of the founders of epidemiology for his work identifyingindicator of fecal pollution and possible pathogenic organisms. the source of a cholera outbreak in 1854. He was born intoSince industrial wastes did not contain these coliform a labourer’s family on 15 March 1813 in York and at 14 was • 11 •
  14. 14. apprenticed to a surgeon. At the time, it was assumed that infections. Lind died in 1794 in Gosport.cholera was airborne. However, Snow did not accept this Robert Koch (1843 - 1910)‘miasma’ (bad air) theory, arguing that in fact entered the bodythrough the mouth. The French parasitologist Casimir-Joseph Davaine inspired by the work of the French microbiologistHe published his ideas in an essay ‘On the Mode of Louis Pasteur had showed, in 1863, Communication of Cholera’ in 1849. A that anthrax in sheep was due to the few years later, Snow was able to prove presence of rod-like bodies in the his theory in dramatic circumstances. In blood. Koch announced that he had August 1854 a cholera outbreak occurred isolated and grown, the tubercle in Soho. It was common at the time to bacillus to the Physiological Society of have a cesspit under most homes. Most Berlin on 24 March 1882. He believed families tried to have their raw sewage this to be the cause of all forms of collected and dumped in the Thames to tuberculosis. prevent their cesspit from filling faster than the sewage could decompose into The outbreak of cholera in Egypt and the danger of it findingthe soil. After careful investigation, including plotting cases of its way to Europe, caused Koch, as a member of the Germancholera on a map of the area, Snow was able to identify a water government commission, to go to Egypt to investigate thepump in Broad (now Broadwick) Street as the source of the disease. Although he was frustrated by the cessation of thedisease. He had the handle of the pump removed and cases of epidemic, he was able to study the disease long enough tocholera immediately began to diminish. Snow later used a spot suspect a particular comma-shaped bacillus. Whilst there,map to illustrate how cases of cholera were centred around the however he was able to discover the cause of amoebic dysenterypump. He showed that companies taking water from sewage- and the bacilli of two varieties of Egyptian conjunctivitis. Hepolluted sections of the Thames delivered water to homes with was able to complete his work on cholera by proceeding toan increased incidence of cholera. Snow’s study was a major India. He discovered the cholera organism and its transmissionevent in the history of public health and can be regarded as the via drinking water, food and clothing. When he returned tofounding event of the science of epidemiology. Berlin Koch advised regular checks on the water supplies and  recommendations regarding sewage disposal. He also organisedSnow was also a pioneer in the field of anaesthetics. In courses in the recognition of cholera. Koch investigated the1853and 1857, he was responsible for giving chloroform to effect an injection of dead bacilli would have on a person whoQueen Victoria at the birth of her son Leopold and daughter subsequently received a dose of living ones. He concluded thatBeatrice. Snow died of a stroke on 16 June 1858. the local reaction produced might provide the means by whichJames Lind (1716 - 1794) the disease could not only be diagnosed but, in the early stages,Lind was a Scottish doctor, a pioneer of naval hygiene and perhaps even cured. He used as the active agent a sterile liquid expert on the treatment of scurvy. James produced from cultures of the bacillus. As the liquid (tuberculin, Lind was born in Edinburgh in 1716. In 1890) proved disappointing as a curative agent its importance 1747, while serving as surgeon on HMS as a means of detecting a present or past tubercular state was Salisbury, he carried out experiments to not immediately recognised. discover the cause of scurvy, the symptoms The result of Koch investigations into a bubonic plague epidemic of which included loose teeth, bleeding in Calcutta in 1897 showed that rats were vectors of the disease. gums and haemorrhages. He also demonstrated that sleeping sickness is transmitted by Lind selected 12 men from the ship, all the tsetse fly. Other studies by Koch included leprosy, surra, suffering from scurvy and divided them rinderpest, Texas fever and malaria. In 1905 Koch won theinto six pairs, giving each group different additions to their Nobel Prize for Physiology or Medicine for investigation andbasic diet. Some were given cider, others seawater, others a discoveries in relation to tuberculosis.mixture of garlic, mustard and horseradish. Another group of Joseph Lister (1827-1912)two were given spoonfuls of vinegar and the last two oranges By the middle of the nineteenth century, post-operative sepsisand lemons. Those fed citrus fruits experienced a remarkable infection accounted for the death of almostrecovery. While there was nothing new about his discovery - half of the patients undergoing majorthe benefits of lime juice had been known for centuries - Lind surgery. A common report by surgeons washad definitively established the superiority of citrus fruits ‘operation successful but the patient died’.above all other ‘remedies’. In 1753, he published ‘A Treatise of Sepsis was considered as a kind ofthe Scurvy’ and in 1757 ‘An Essay on the Most Effectual Means combustion caused by exposing moistof Preserving the Health of Seamen in the Royal Navy’, which body tissue to oxygen. It was thereforethrew much light on the appalling living conditions and diet of considered that the best prevention was toseamen. In 1763, Lind published work on typhus fever in ships keep air away from wounds by means ofand in the 1768 publication ‘An Essay on Diseases Incidental plasters, collodion or Europeans in Hot Climates’ he summarised the prevalentdiseases in each colony and gave advice on avoiding tropical Joseph Lister, a British surgeon, considered that infection was not due to bad air alone and that ‘wound sepsis’ was a form • 12 •