P And SM (Preventive And Social Medicine), - Uttarakhand PCS Exam Notes

P and SM (Preventive and Social Medicine)

The name preventive and social medicine emphasizes the role of:

Disease prevention in general through immunization, adequate nutrition, etc. in addition to the routine hygiene measures, and
Social factors in health and disease.

The name preventive and social medicine has gained wide acceptance in the past twenty-five years or so because of its broader and more comprehensive outlook on medicine, integrating both prevention and cure.
Today, it implies a system of total health care delivery to individuals, families and communities at the clinic, in the hospital and in the community itself.

Public Health

It was defined by Winslow (1851) as the science and art of preventing disease, prolonging life and promoting health and efficiency through organized community measures such as control of infection, sanitation, health education, health services and legislation, etc.
Public Health developed in England around the middle of the nineteenth century. Edwin Chadwick, a pleader, the then Secretary of Poor Law Board (constituted under Poor Law Act passed in 1834) championed and cause of community health and the first Public Health Act was passed in 1848.
This signified the birth of public health. Public Health in India followed the English pattern but the progress was extremely slow during the British regime.
It started after 1858 when a Royal Commission was sent to find the reasons for heavy morbidity and mortality among European troops in India due to malaria and some other preventable diseases.
The Public Health Departments started as vaccination departments and later as Sanitation Departments at the Center as well as in the Provinces around 1864.
There was a long tussle whether the Sanitation or Public Health Department should be responsible directly to the Government or to the Surgeon General-in-Charge of Hospitals and Medical Education.
It took almost 40 years for the British Government to decide in 1904 that Public Health Departments should function separately.
The designations of Sanitary Commissioner and Assistant Sanitary Commissioner were changed to those of Director and Assistant Director of Public Health.
Thus curative and preventive departments worked separately as Medical and Public Health Departments.
This continued in India even after independence for some time, though the idea of integration started at the beginning of the Second World War. A recommendation to this effect was made by the Bhore Committee in 1946.

Preventive Medicine

Preventive medicine developed as a specialty only after Louis Pasteur propagated in 1873 the germ theory of disease followed by discovery of causative agents of typhoid, pneumonia, tuberculosis, cholera and diphtheria within the next decade. It gained further impetus during subsequent years from the following developments:

Development of several specific disease preventive measures before the turn of the century (antirabies treatment, cholera vaccine, diphtheria antitoxin and antityphoid vaccine).
Discovery and development of antiseptics and disinfectants.
Discovery of modes of transmission of diseases caused by germs.

Transmission of malaria, yellow fever and sleeping sickness had been elucidated before the turn of the century. It may be said in retrospect that when public health gained roots with the passage of the Public Health Act, the emphasis was on environmental sanitation alone With the advent of the specialty of preventive medicine, emphasis was also given to prevention of diseases. These included not only infective diseases but also others such as nutritional deficiency diseases

Social Medicine

It is defined as the study of the man as a social being in his total environment. It is concerned with the health of groups of individuals as well as individuals within groups. The term social medicine gained currency in Europe around 1940. In 1949, a separate department of Social Medicine was started at Oxford by Professor Ryle. The concept of social medicine is based upon realization of the following facts:

Suffering of man is not due to pathogens alone. It can be partly considered to be due to social causes (social etiology).
The consequences of disease are not only physical (pathological alterations due to pathogens) but also social (social pathology).
Comprehensive therapeutics has to include social remedies in addition to medical care (social medicine).
Social services are often needed along with medical care services. Interest in social medicine began to decline with the development of epidemiology.

The Royal Commission on Medical Education substituted in 1968 the term social medicine by community medicine in its report (Todd Report).

Preventive and Social Medicine

As clarified above, preventive medicine and social medicine cover different areas, though both are concerned with health of the people.
This is why the combined name Preventive and Social Medicine was suggested to provide a holistic approach to health of the people.
This name was preferred to the earlier name public health because the former had come to be visualized as a discipline dealing mainly with sanitation, hygiene and vaccination.
However, the term public health has now once again become fashionable in England.

Community Medicine

It has been defined as “The field concerned with the study of health and disease in the population of a defined community or group. Its goal is to identify the health problems and needs of defined populations (community diagnosis) and to plan, implement and evaluate the extent to which health measures effectively meet these needs”.
Broadly, one could state that community medicine, while encompassing the broad scope of preventive and social medicine, lays special emphasis on providing primary health care.
It may be remembered that five of the eight components of primary health care, are related to clinical activities.
The modern day message is that the discipline variously labelled in the past as public health or preventive and social medicine cannot be divorced from health care, including clinical care of the community.
It is in recognition of this wider role that the Medical Council of India has recently decided to label the discipline as Community Medicine in place of Preventive and Social Medicine.
In a recent case decided by the Supreme Court of India the issue was whether the Department of Preventive and Social Medicine in a Medical College is a Clinical or Paraclinical Department. It was held that it is a Clinical Department.

Epidemiological Approach in Preventive and Social Medicine

Dictionaries define epidemiology as the scientific basis for public health and, especially, preventive medicine.
In keeping with this concept, this concept is patterned on the epidemiological approach, which is symbolized in the triad of host, agent and environment.
To put it rather picturesquely, just as there are three components in a drama on the stage, there are three components in the drama of disease as well.
The stage drama or a movie is built around a hero, a villain and the life circumstances in which they operate and interact.
The disease drama has similar components of hero (the host), villain (the agent of disease) and circumstances (the environment).
To summarize, the three epidemiological components of a disease situation are:

The host or the man who enjoys health or suffers from disease (The World Health Organization defines health as a state of complete physical, mental and social wellbeing and not mere absence of disease or infirmity.
The agents, whether living (such as bacteria and viruses) or nonliving (such as radiation, temperature and minerals, e.g. lead, fluorine).
The environment comprising of food, air, water, housing, place of work, etc. which surround both the host and the agent and in which both interact.

The outcome of the host agent environment interaction may be in the nature of health, discomfort, disability, disease or death.
Thus all individuals in a population group may be equally exposed to the same agent and environment, yet some may totally escape the disease, others may get only a mild attack while yet others may develop the full blown disease which may culminate in death. This is so because the exact outcome is determined by host factors inherent in each individual.

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