INTRODUCTION TO COMMUNITY MEDICINE Dr Ghazala Yasmin Lecturer Community Medicine Department

CONCEPT OF COMMUNITY MEDICINE Community medicine is synonymous with Population medicine, which deals with health & disease at community level. It is also referred to as Hygiene Public Health Preventive Medicine Social Medicine COMMUNITY MEDICINE It is the art & science of application of technical knowledge & skills to the delivery of health care to a given community, designed in collaboration with related professions as well as human & social sciences on the one hand, and community on the other. COMMUNITY MEDICINE A SYSTEM OF DELIVERY OF COMPREHENSIVE HEALTH CARE TO THE PEOPLE BY A HEALTH TEAM IN ORDER TO IMPROVE THE HEALTH OF COMMUNITY . COMMUNITY A LARGE NUMBER OF INDIVIDUALS LIVING TOGETHER IN A DEFINED GEOGRAPHICAL AREA & HAVING COMMON INTERESTS, GOALS & WAYS OF LIFE. Examples: Mahallah in cities, villages. MEDICINE THE BRANCH OF SCIENCE THAT DEALS WITH DIAGNOSIS, TREATMENT AND MAINTENANCE OF HEALTH IS CALLED MEDICINE. WHO Definition of HEALTH IT IS A STATE OF PHYSICAL, MENTAL, SOCIAL & SPIRITUAL WELL-BEING & ABILITY TO FUNCTION & NOT MERELY THE ABSENCE OF DISEASE OR INFIRMITY . Health

The function here refers to optimum level of function (OLOF) and emphasizes an ability to live an economically productive life. PREVENTIVE MEDICINE It is the science & art of preventing disease, prolonging life & promoting physical & mental health and efficiency. It is applied to preventive medicine practiced either by A medical or dental practitioner dealing with an individual patient in a clinic or hospital. As a public health manager (health physician) dealing with groups of people in his community. PREVENTIVE MEDICINE Preventive medicine include measures like Health Promotion Specific Protection Prevention of Disability It includes all three levels of prevention, most important being primary prevention. Pioneers in this field are John Snow (Cholera Epidemic) James Lind (Prevention of Scurvy) Edward Jenner (Vaccination against Smallpox) John Snow Father of Epidemiology John Snow, M.D. (1813--1858) A legendary figure in epidemiology provided one of the earliest examples of using epidemiologic methods to identify risk for disease and recommend preventive action. Best known for his work in anesthesiology, Snow also had an interest in cholera and supported the unpopular theory that cholera was transmitted by water rather than through miasma (i.e., bad air). On August 31, 1854, London experienced a recurrent epidemic of cholera; Snow suspected water from the Broad Street pump as the source of disease. To test his theory, Snow reviewed death records of area residents who died from cholera and interviewed household members, documenting that most deceased persons had lived near and had drunk water from the pump. Snow presented his findings to community leaders, and the pump handle was removed on September 8, 1854. Removal of the handle prevented additional cholera deaths, supporting
2

Snow's theory that cholera was a waterborne, contagious disease. Despite the success of this investigation, the cause of cholera remained a matter of debate until Vibrio cholerae was isolated in 1883. Edward Jenner found Vaccination against Smallpox. James Lind was a Naval surgeon & he found the cause of Scurvy, which lead to death of thousands of sailors. Social Medicine It is the study of man in his total environment which may be Physical, Biological & Socioeconomic. It is concerned with Curative Medicine Health Promotion & Prevention of Disease. It is concerned with factors that influence the utilization and effectiveness of the health and health related services. SOCIAL HYGIENE Social Hygiene refers to the science of prevention and treatment of sexually transmitted infections, previously known as Venereal Diseases. This does not only include prevention & treatment but also Rehabilitation of the patients & Contract Tracing. Social Evils Drug abuse Child abuse Sexual abuse/ prostitution Theft Robbery Murder Beggary Kidnapping COMPREHENSIVE HEALTH CARE It is the delivery of personal and impersonal health services to the community for prevention of disease, cure of illness, prevention of disability, economic insecurity and dependency associated with illness. Personal Health Services These are health services that are directly directed for the care of the person e.g. maternal and child health care, occupational health services and school health services
3

PERSONAL HEALTH SERVICES

Impersonal Health Services These are the community health services that indirectly influence the health of the person e.g. safe water supply, safe excreta disposal and vector control measures. PRINCIPLES OF COMPREHENSIVE HEALTH CARE Availability Accessibility Acceptability Affordability Comparison of Clinical and Community Medicine

Public Health It is the science and art of preventing disease, prolonging life, promotion physical and mental health and efficiency through organized community efforts for: The sanitation of the environment. The control of communicable diseases. Education of the individual in personal hygiene. The organization of medical and nursing services for the early diagnosis, and preventive treatment of disease. The development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. What does Public Health do?

Provide disease control and prevention Assure air and water quality Promote healthy lifestyles It helps people: Save money Enjoy good health Live longer COME COME stands for Community Oriented Medical Education. It is a teaching methodology to produce community oriented doctors who are not only able to but also willing to serve the communities at primary, secondary and tertiary health care levels. In short, it is relevant medical education to the needs of the community CBL It is community based learning and is defined as a learning process through tasks/ assignments, of students outside the teaching hospitals in places like schools, homes, slums, work places etc. Iceberg Phenomenon An iceberg is a large mass of ice which has detached from a glacier. The iceberg floats on the surface of water. Only its tip that is a small portion is visible while the bulk of it is submerged and not visible. Analogous to this, the cases of disease that are reported or are seen by the physicians are much fewer as compared to the people who remain undetected. These undetected cases are latent, inapparent, subclinical or presymptomatic, carriers or undiagnosed cases. The undetected part or sumberged part is a large reservoir of disease.

The reason why affected people may go undiagnosed or unreported could be due to a lack of health facilities or a lack of tests for picking up subclinical cases. Trends in the people to undergo period examinations, the nature of the disease, integrity of a surveillance reporting system and availability of screening programmes all contribute to the size of the submerged portion. For example it is believed that the number of reported HIV positive cases in Pakistan are far less than the number of unreported cases who remain largely undiagnosed. Iceberg Phenomenon of Disease This refers to symptomless cases or sub-clinical cases that may exist in a community. If a large block of ice floats in water, a small portion of the ice is visible above the surface of water while a large portion is submerged and remains invisible. Symptomless case correspond to that large portion of ice which is submerged. This phenomenon is known as Iceberg of the disease. Iceberg phenomenon of disease gives a picture of the spectrum of diseases in a community. The visible part of the iceberg denotes the clinically apparent cases of disease in the community. The part of the iceberg below the water level denoted the latent, subclinical, undiagnosed and carrier states in the community, which forms the major part. The hidden part is especially important in disease like hypertension, diabetes and malnutrition. Iceberg Phenomenon of Disease Some diseases exhibiting iceberg phenomenon: Diabetes Hypertension Malnutrition Polio Leprosy Celiac Disease: An autoimmune disease, ingestion of Gluten present in wheat, barley & rye causes the damage to mucosa of the small intestine. Prevalence : 1% with M:F= 2:1 to 3:1. Presenting with diarrhea, wt. loss, hypocalcemia & hypoproteinemia. Iceberg concept of infection
Severe symptoms (colds) Mild symptoms (few sneezes etc.)

Infection but no symptoms Exposure but no infection

The epidemiologic triad 7

Not everyone who is exposed to an infectious agent or an environmental contaminant will have an adverse health event such as becoming infected or developing a disabling condition. Likewise, among those who do become infected or debilitated, the symptoms and severity may vary greatly due to many factors. Some important variables include: Sex Age Race Occupation Nutritional status Place of residence, Risk-taking and health-seeking behaviors Immunity Education Availability of health care Passive (mother-to-child)or acquired (previous vaccination) immunity

exposure and

Epidemiologic Triad A traditional model of infectious disease causation, known as the Epidemiologic Triad. The triad consists of an external agent, a host and an environment in which host and agent are brought together, causing the disease to occur in the host.

A vector, an organism which transmits infection by conveying the pathogen from one host to another without causing disease itself, may be part of the infectious process. Agent A disease agent is defined as an element or a substance, animate or inanimate, the presence (or absence) of which may initiate or

perpetuate a disease process. Disease agents are classified into the following types Disease agents are classified into the following types

Biologic Agent: These are living and include various viruses, bacteria, fungi etc. These agents have certain properties such as infectivity, pathogenicity and virulence.

Infectivity capacity to multiply in or on the tissue of the host. Virulence ability to invade and damage tissues of the host. Pathogenicity The capability of an infectious agent to cause disease in a susceptible host. Physical Agents: Physical agents include exposure to excessive heat, cold, humidity, pressure, radiation, electricity, sound waves, etc. Mechanical Agent e.g. chronic friction, associated with the use of drill machines used by road builders Chemical Agent Endogenous: These are produced inside the body as a result of some abnormality e.g. excessive urea leading to ureamina, or excessive bilirubin leading to jaundice or increased ketone bodies leading to ketoacidosis. Exogenous: those arising outside the body including dusts, gases, fumes, metals, allergens, insecticides etc. Host factors Which make a person susceptible to a disease, include Demographic characteristics e.g. age, sex etc Biological characteristics such as genetic factors, blood groups, enzymes, immune status, blood pressure etc. intercurrent or preexisting disease (lillienfied 1980) Life style factors such as habits, life style whether sedentary or active, smoke etc Environmental factors in disease occurrence and distribution

These factors are responsible for exposing the host to the agent. Environment is defined as the aggregate of all external conditions and influences affecting the life and development of an organism. Human behavior or society The environment can be classified into the following types. Biological Environment this includes agents of biological infections, reservoirs of infection, disease vectors, plants and animals. Environment Psycho-social Environment This includes the social and political organization of the country, the availability and accessibility of health services, the general life style of the people, socio cultural patterns beliefs and values, traditions and habits, educational level and religion of the people. Physical Environment It includes factors like heat, noise, radiation, air, soil A classic example of a vector is the Anopheles mosquito. As the mosquito ingests blood from an infected host, it picks up the parasite plasmodium. The plasmodium is harmless to the mosquito. However, after being stored in the salivary glands and then injected into the next human upon whom the mosquito feeds, the plasmodium can cause malaria in the infected human. Epidemiologic Triad of Disease Causation (Historical)

10