Dr. Farooq Lecture

History of Medicine History of Medicine (Evolution of Community (Evolution of Community

Medicine)Medicine)

Dr. Farooq AhmadDr. Farooq AhmadAssistant Professor Assistant Professor Community Medicine DepartmentCommunity Medicine Department

Rawalpindi Medical CollegeRawalpindi Medical CollegeRawalpindiRawalpindi

Evolution of Community Evolution of Community MedicineMedicine(History of Medicine)(History of Medicine)Stages seen in the history of medicine:Stages seen in the history of medicine:

• Stone ageStone age

• 5000 BC: Indian medicine5000 BC: Indian medicine

• 2700 BC: Chinese medicine (system of 2700 BC: Chinese medicine (system of barefoot doctor, System of barefoot doctor, System of acupuncture)acupuncture)

• 2000 BC: Egyptian medicine 2000 BC: Egyptian medicine (manuscript of papyrus)(manuscript of papyrus)

Continued…..

Stages seen in the history of medicine:Stages seen in the history of medicine:

• 2000 BC: Mesopotamian medicine 2000 BC: Mesopotamian medicine (Babylonian code of hammurabi) (Babylonian code of hammurabi)

• 460 BC: Greek medicine (Hygiea 460 BC: Greek medicine (Hygiea daughter daughter of Aescuapius, of Aescuapius, Hippocrates oath)Hippocrates oath)

• 130 AD: Roman medicine (Galen)130 AD: Roman medicine (Galen)

• Up to 800 AD: Dark ages of medicineUp to 800 AD: Dark ages of medicine

Evolution of Community Evolution of Community MedicineMedicine(History of Medicine)(History of Medicine)

Continued…..


• 900 AD: Arabic medicine (Rhazes, Avicenna)900 AD: Arabic medicine (Rhazes, Avicenna)

• 1500 AD: Revival period (theory of contagion 1500 AD: Revival period (theory of contagion blood circulation by Harvey, blood circulation by Harvey,

vaccination by Jenner)vaccination by Jenner)

• 1800: 1800: Sanitary awakening Sanitary awakening

• 1850: 1850: Rise of public health (epidemic of Rise of public health (epidemic of cholera by John Snow, typhoid by cholera by John Snow, typhoid by

William, Chadwick’s sanitary reforms) William, Chadwick’s sanitary reforms)


Continued…..


• 1860: Germ theory (anthrax by Robert 1860: Germ theory (anthrax by Robert Koch) Koch)

• 1880: Typhoid & pneumonia 1882 TB1880: Typhoid & pneumonia 1882 TB

• 1883: Birth of preventive medicine (ARV)1883: Birth of preventive medicine (ARV)

• 1883: Cholera vaccine, 1892 dipth 1883: Cholera vaccine, 1892 dipth antitoxin antitoxin

• 1898: Malaria transmission by Ross1898: Malaria transmission by Ross


Continued…..


• 1900: Multifactorial causation of 1900: Multifactorial causation of diseasedisease

• 1911: Social medicine1911: Social medicine

• 1920: Disease control1920: Disease control

• 1960: Health promotion1960: Health promotion

• 1981: HFA1981: HFA


Concept of HealthConcept of Health

•Biomedical conceptBiomedical concept

•Ecological conceptEcological concept

•Psychological conceptPsychological concept

•Holistic conceptHolistic concept

Concept of HealthConcept of Health

WHO Definition of HealthWHO Definition of Health

Health is a state of complete physical, Health is a state of complete physical, mental and social well-being and not merely mental and social well-being and not merely an absence of disease or infirmityan absence of disease or infirmity

and ability to lead socially and economically productive lifeand ability to lead socially and economically productive life

Operational definition:Operational definition:A condition or quality of human organism expressing the adequate A condition or quality of human organism expressing the adequate functioning of the organism in giving condition, genetic or environmentalfunctioning of the organism in giving condition, genetic or environmental

Dimensions of healthDimensions of health

1.1. Physical Physical

2.2. MentalMental

3.3. SocialSocial

4.4. SpiritualSpiritual

5.5. EmotionalEmotional

6.6. VocationalVocational7.7. Others:Others:

1.1. CulturalCultural

2.2. SocioeconomicSocioeconomic

3.3. EnvironmentalEnvironmental

4.4. EducationalEducational

5.5. NutritionalNutritional

6.6. CurativeCurative

7.7. PreventivePreventive

Concept of WellbeingConcept of Wellbeing

• Objective component Objective component 1.1. Standard of living Standard of living

2.2. Level of livingLevel of living

• Subjective componentSubjective component• Quality of Life (PQLI)Quality of Life (PQLI)

(IM, Life expt. @ 1, Literacy.)(IM, Life expt. @ 1, Literacy.)

• Human development IndexHuman development Index(Life expt. @ 0, Knowledge, Income)(Life expt. @ 0, Knowledge, Income)

• Subjective componentSubjective component• Quality of Life (PQLI)Quality of Life (PQLI)

(IM, Life expt. @ 1, Literacy.)(IM, Life expt. @ 1, Literacy.)

The condition of life resulting from combination of the factors The condition of life resulting from combination of the factors such as those determining health happiness education social such as those determining health happiness education social and intellectual attainments freedom of action, justice and and intellectual attainments freedom of action, justice and

freedom of expressionfreedom of expression

• Human development IndexHuman development Index(Life expt. @ 0, Knowledge, Income)(Life expt. @ 0, Knowledge, Income)

Concept of WellbeingConcept of Wellbeing

Determinants of healthDeterminants of health

1.1. Biological / HereditaryBiological / Hereditary

2.2. Behavioral & Socio-cultural Lifestyle Behavioral & Socio-cultural Lifestyle


4.4. Socioeconomic conditionsSocioeconomic conditions

5.5. Health and family welfare servicesHealth and family welfare services

6.6. Aging of the populationAging of the population

7.7. Gender Gender

8.8. Others…..Others…..

Determinants of healthDeterminants of health

1.1. Biological Biological

2.2. Behavioral Behavioral


4.4. SocioeconomicSocioeconomic

5.5. Health systemHealth system

6.6. Socio-culturalSocio-cultural

7.7. Aging of the Aging of the populationpopulation

8.8. Science and Science and technologytechnology

9.9. Information and Information and communicationcommunication

10.10.GenderGender

11.11.Equality and Equality and social justice social justice

12.12.Human rights Human rights

Responsibility of HealthResponsibility of Health

1.1. Individual responsibilityIndividual responsibility

2.2.Community responsibilityCommunity responsibility

3.3.State responsibilityState responsibility

4.4. International responsibilityInternational responsibility

Indicators of healthIndicators of health(Valid Reliable Sensitive Specific)(Valid Reliable Sensitive Specific)

1.1. Mortality indicatorsMortality indicators2.2. Morbidity indicatorsMorbidity indicators3.3. Disability indicatorsDisability indicators4.4. Nutritional Status indicatorsNutritional Status indicators5.5. Health care delivery indicatorsHealth care delivery indicators6.6. Utilization rateUtilization rate7.7. Indicators of social and mental healthIndicators of social and mental health8.8. Environmental indicatorsEnvironmental indicators9.9. Socioeconomic indicatorsSocioeconomic indicators10.10.Health policy indicatorsHealth policy indicators11.11.Indicators of quality of lifeIndicators of quality of life12.12.Others……….Others……….

Health IndicatorsHealth Indicators

Valid, reliable, sensitive and relevant indicators which Valid, reliable, sensitive and relevant indicators which determine health development are called health determine health development are called health indicators:indicators:

• Mortality Indicators: Mortality Indicators: Death rate, Life span, IMR, Child mortality Death rate, Life span, IMR, Child mortality rate, rate, MMR, Case fatality rate, proportion MMR, Case fatality rate, proportion mortality rate.mortality rate.

• Morbidity Indicators: Morbidity Indicators: Disease rate (incidence, prevalence)Disease rate (incidence, prevalence) • Disability Indicators: Disability Indicators: Hospitalization, loss of work, sullivan index Hospitalization, loss of work, sullivan index

DALYsDALYs

• Nutritional Indicators: Nutritional Indicators: Anthropometric values, LBWAnthropometric values, LBW • Utilization Indicators: Utilization Indicators: Fully immunized, bed turn out…Fully immunized, bed turn out…

• Socioeconomic Indicators: Socioeconomic Indicators: Per capita income. Family size.Per capita income. Family size.

Mortality indicatorsMortality indicators

1.1. Crude death rateCrude death rate

2.2. Expectancy of lifeExpectancy of life

3.3. Infant mortality rateInfant mortality rate

4.4. Child Mortality rateChild Mortality rate

5.5. Under 5 proportionate mortality rateUnder 5 proportionate mortality rate

6.6. Maternal mortalityMaternal mortality

7.7. Disease specific mortalityDisease specific mortality

8.8. Proportionate mortality rate Proportionate mortality rate

Concept of Concept of diseasediseaseIt is departure from state of health interrupting in It is departure from state of health interrupting in normal function of the bodynormal function of the body

Concept of diseaseConcept of disease• Theories Theories of causation of disease of causation of disease • (Germ theory, Epidemiological Triad, Multifactorial causation, web of causation) (Germ theory, Epidemiological Triad, Multifactorial causation, web of causation)

• Natural History of diseaseNatural History of disease(Prepathogenesis – pathogenesis) (Prepathogenesis – pathogenesis) ((Agent Agent Host Host Environment)Environment)

• Risk Factors Risk Factors

• Iceberg PhenomenaIceberg Phenomena• Monitoring Monitoring tthe performance & analysis of he performance & analysis of routine measurements aimed at routine measurements aimed at

detecting changes detecting changes in the environment or health status of population in the environment or health status of population

• Surveillance Surveillance The The continuous scrutiny of the factors that determines the continuous scrutiny of the factors that determines the occurrence and distribution of disease occurrence and distribution of disease and other conditions of ill health and other conditions of ill health

• Sentinel Surveillance Sentinel Surveillance

• Prevention and Control Prevention and Control

Difference between Difference between

Control & EradicationControl & Eradication

ControlControl EradicationEradicationDefinitionDefinition To reduce incidence To reduce incidence

to acceptable levelto acceptable levelTotal extirpation of Total extirpation of disease agent disease agent

ObjectiveObjective To reduce morbidity To reduce morbidity & mortality & mortality (no more PH (no more PH problem)problem)

To uproot the To uproot the diseasedisease

Area of operationArea of operation In high incidence In high incidence areaarea

Total coverage Total coverage

Duration of Duration of operation operation

IndefiniteIndefinite Time limitedTime limited

Economic aspectEconomic aspect RecurringRecurring CheapCheap

Case finding, Case finding, Confirmation, Confirmation, Epidemiological Epidemiological investi.investi.

Not importantNot important Very ImportantVery Important

Examples of Risk FactorsExamples of Risk Factors

Fatty diet, obesityFatty diet, obesity Diabetes Diabetes

AlcoholAlcohol Cirrhosis of liverCirrhosis of liver

Smoking, radiationSmoking, radiation CancerCancer

High cholesterol, obesity, High cholesterol, obesity, type of personalitytype of personality

Heart diseasesHeart diseases

Smoking, high BP, high Smoking, high BP, high cholesterolcholesterol

StrokeStroke

Alcohol, Ignorance about Alcohol, Ignorance about traffic signals traffic signals

AccidentAccident

LEVEL OF LEVEL OF PREVENTIONPREVENTION

1.1. Primordial PreventionPrimordial Prevention

2.2. Primary PreventionPrimary Prevention

3.3. Secondary PreventionSecondary Prevention

4.4. Tertiary PreventionTertiary Prevention

Natural history of diseaseNatural history of diseaseInterrelation of Agent , Host and Interrelation of Agent , Host and

Environmental FactorEnvironmental FactorReaction of the host to the stimulusReaction of the host to the stimulus

Production of stimulusProduction of stimulus Early Early pathogenespathogenes

isis

Discernible Discernible early early

lesionslesions

Advance Advance diseasedisease

ConvalescenConvalescencece

Pre-pathogenesis periodPre-pathogenesis period Period of Pathogenesis Period of Pathogenesis

Health Health PromotionPromotion

Specific Specific protectionprotection

Early diagnosis & Early diagnosis & prompt treatmentprompt treatment

Disability Disability limitationlimitation

RehabilitationRehabilitation

•Health EducationHealth Education

•Good standard of Good standard of nutrition adjusted to nutrition adjusted to developmental developmental phases of lifephases of life

•Attention of Attention of personality personality developmentdevelopment

•Provision of Provision of adequate housing adequate housing recreation & recreation & agreeable working agreeable working cond.cond.

•Marriage Marriage counseling ang sex counseling ang sex educationeducation

•GeneticsGenetics

•Periodic selective Periodic selective examinationexamination

•Use of specific Use of specific immunizationimmunization

•Attention to Attention to personal hygienepersonal hygiene

•Use of Use of environmental environmental sanitationsanitation

•Protection against Protection against occupational hazardsoccupational hazards

•Protection from Protection from accidentsaccidents

•Use of specific Use of specific nutrientsnutrients

•Protection of Protection of carcinogens carcinogens

•Avoidance of Avoidance of allergensallergens

•Case finding Case finding measures individual & measures individual & massmass

•Screening surveysScreening surveys

•Selective Selective examinations examinations objectivesobjectives

To cure & prevent To cure & prevent disease processdisease process

To prevent the spread To prevent the spread of a communicable of a communicable diseasesdiseases

To prevent To prevent complications & complications & sequelsequel

To shorten period of To shorten period of disabilitydisability

•Adequate Adequate treatment to treatment to arrest the arrest the disease disease process and process and to prevent to prevent further further complicationcomplications s

•Provision of Provision of facilities to facilities to limit limit disability and disability and to prevent to prevent deathdeath

•Provision of Provision of hospital & hospital & community community facilities for facilities for retaining & retaining & education for education for maximum use of maximum use of remaining remaining capacitiescapacities

•Education of Education of public & industry public & industry the rehabilitated the rehabilitated

•As full As full employment as employment as possiblepossible

•Selective Selective placementplacement

•Work therapy in Work therapy in hospitalshospitals

•Use of shelter Use of shelter colonycolony

Primary preventionPrimary prevention Secondary Secondary PreventionPrevention

Tertiary preventionTertiary prevention

Modes of InterventionModes of InterventionIIntervention is an attempt to intervene or interrupt the ntervention is an attempt to intervene or interrupt the

usual usual sequence in the development of disease in a man.sequence in the development of disease in a man.

1.1. Health Promotion:Health Promotion: It is a process of enabling people to increase It is a process of enabling people to increase control over & to improve healthcontrol over & to improve health

– Health educationHealth education– Environmental healthEnvironmental health– Nutritional interventionNutritional intervention– Lifestyle changesLifestyle changes– Behavior changes Behavior changes

2.2. Specific Protection:Specific Protection:It is a process to totally avoid disease or It is a process to totally avoid disease or illnessillness– ImmunizationImmunization– Nutritional supplementNutritional supplement– ChemoprophylaxisChemoprophylaxis– ImmunoprophylaxisImmunoprophylaxis– Protective device in industryProtective device in industry– Protective device against carcinogenProtective device against carcinogen– Protective device against allergensProtective device against allergens

Modes of InterventionModes of Intervention

3.3. Early diagnosis and prompt Early diagnosis and prompt treatmenttreatment

It is a process of early detection of transformation from It is a process of early detection of transformation from physiological to pathological statephysiological to pathological state

Early diagnosis and prompt treatment of:Early diagnosis and prompt treatment of:• Ca breastCa breast

• Ca cervixCa cervix

• TBTB

• LeprosyLeprosy


4.4. Disability LimitationDisability LimitationIt is a process involving interaction to It is a process involving interaction to prevent disability e.g.prevent disability e.g.– Disability limitation in nerve damage in Disability limitation in nerve damage in

leprosyleprosy– Physiotherapy in polio lameness.Physiotherapy in polio lameness.

ImpairmentImpairment DisabilityDisabilityHandicapHandicap


5.5. RehabilitationRehabilitationIt is a combine & co-ordinate use of medical, It is a combine & co-ordinate use of medical, social, economical, vocational and psychological social, economical, vocational and psychological measure to make an individual or community measure to make an individual or community function normallyfunction normally

– Medical rehabilitationMedical rehabilitation– Social rehabilitation Social rehabilitation – Economic rehabilitationEconomic rehabilitation– Vocational rehabilitationVocational rehabilitation– Psychological rehabilitationPsychological rehabilitation


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Dr. Farooq Lecture