SCOPE OF COMMUNITY MEDICINE

Dr.Suneeta.Nyamannavar Postgraduate Student Dept of CommunityMedicine, KIMS,Hubli

What is Community Medicine?

The study of health and disease in the population of defined communities or groups in order to identify their health needs, and to plan, implement, and evaluate health programs to effectively meet these needs

DEFINITION
The Faculty of Community Medicine of the Royal College of Physicians has defined community medicine as "that speciality which deals with populations......and comprises those doctors who try to measure the needs of the population, both sick and well, who plan and administer services to meet those needs, and those who are engaged in research and teaching in the field"

What are the Goals of Community Medicine? Protection & Promotion of Public Health.

How Community Medicine differs from other branches of Medicine?

Community Medicine reaches out to people to provide 1. Services for prevention of disease (such as immunization, pre-natal care, health screening etc.), 2. Promotion of health (such as safe water supply and sanitation, vector control measures, tobacco control policy etc.) and 3. Provision of primary medical care (treatment of common ailments such as diarrhea, pneumonia, TB, leprosy, malaria, hypertension etc.) whereas other branches of medicine largely provide diagnostic and treatment services to patients who seek treatment.

 Is Community Medicine different from Public Health? In India Community Medicine is synonymous with what is known as Public Health Medicine or Public Health in other countries.

Who are Community Medicine Specialists?

Medical doctors who have done MBBS and a three year Doctor of Medicine (MD) course in Community Medicine during which they are trained in Epidemiology and Bio-statistics Health Planning and Health Management Health Education and Health Promotion Primary Medical care

Community Medicine Specialist

Has in-depth understanding of the determinants of health and diseases. Diagnoses and manages common illnesses and emergencies encountered in the community. Adopts integrated approach to develop policies to meet the health needs of the individual, family and the community. Conducts epidemiological investigations of communicable and non-communicable diseases and suggests appropriate solutions to public health problems. .

Interprets records and reports of health services at various levels of health care delivery system. Performs research and applies research findings to improve health services of the community. Undertakes teaching and training assignments in the field of community medicine for various categories of medical and paramedical personnel. functions as an effective member as well as a leader of the health team

SO .. Scope of this specialty is quite wide ranges from planning & provision of public health services ,to the delivery of primary health care through out the life cycle of human beings (i.e. from child wood to old age) It demands not only study of general medicine covering all the organ systems of human body but also the awareness of the civic, social , legal & economic organization of the society. There fore community specialist has to acquire vast knowledge & range of skills . Have basic understandings & skills to deliver general medicine care & possess in depth knowledge of communicable and non communicable disease ,principles of social & behavior sciences.

Why Study Community Medicine?

1. Treatment of disease Doctors aim should be to treat patients and not just disease Doctor has to know more than clinical medicine; he has to know preventive and social aspects of disease Social Equity Whom to treat? A politician requiring cardiac care or thousands requiring ORS/ immunization Health services planning Needs of many should take precedence over those of few Those in greatest need dont even know of their needs or where to seek Doctors responsibility Apart from theory knowledge and pharma prescriptions, doctor should make treatment available at the price the community and country can afford Patients queries to answer one has to know natural history of disease. Interaction with patients Health team leadership

2. 3.

4.

5. 6. 7.

 There is lot of confusion about DEFINITION ,

SCOPE , & CONTENTS OF PUBLIC HEALTH, PREVENTIVE MEDICINE, PREVENTIVE & SOCIAL MEDICINE & COMMUNITY MEDICINE

Chronologically these terms present a word picture of evolution of the discipline .

 These changing titles characterize ours as a

YOUNG AND DYNAMIC DISCIPLINE EARNESTLY STRIVING TO UNRAVEL ITS TONE POTENTIALS .

History and evolution of community medicine Started around 1500A.D.

FRACASTORIUS(1483-1553): Theory Of Contagion (transfer of infection via minute particles & explained cause of epidemics ). Syphilis (person to person transmission during sexual transmission). Founder of epidemiology. THOMAS SYDENHAM (1624-1689): -D/D of scarlet fever , malaria, dysentery & cholera . First distinguished epidemiologist.

AESCULAPIUS 1200BC

HYGIEA

PANACEA

DEPARTMENT OF HYGIENE

DEPARTMENT OF MEDICINE

DEPARTMENT OF PUBLIC HEALTH(18341848)

PREVENTIVE ASPECT

CURATIVE ASPECT (1873)

DEPARTMENT OF SOCIAL MEDICINE(19401948)

DEPARTMENT OF P&SM

DEPARTMENT OF COMMUNITY MEDICINE

SANITARY AWAKENING
In 1832 EDWIN CHADWICK investigated THE GREAT CHOLERA EPIDEMIC (gave report on sanitary conditions of labouring population ). This became the LAND MARK in the history of public health . It led to ENACTMENT OF PUBLIC HEALTH ACT OF 1848 in England. This gave rise to PUBLIC HEALTH JOHN SNOW is known as FATHER OF PUBLIC HEALTH CHOLERA is also often called as FATHER OF PUBLIC HEALTH.

Sanitary awakening

Department of street cleaning - sweeper roll call , line drawing 1898 LONDON

PUBLIC HEALTH:
C.E.A WINSLOW in 1920 defined public health as science of art of PREVENTING DISEASE PROLONGING LIFE & PROMOTING HEALTH & EFFICIENCY THROUGH ORGANIZED COMMUNITY EFFORT FOR 1) the sanitation of environment 2) control of communicable disease 3) the education of the individual in personal hygiene. 4) organization of medical & nursing services for early diagnosis & prevention of disease . 5) development of social machinery to insure everyone a standard of living .

CHANGING CONCEPTS IN PUBLIC HEALTH

A) DISEASE CONTROL PHASE (1880-1920)sanitary measures.

B) HEALTH PROMOTIONAL PHASE (19201960)- personal health services.

C ) SOCIAL ENGINEERING PHASE (1960-1980): social & behavioral aspects of disese & health were given a new priority

Public health moved in to preventive & rehabilitative aspects of disease & behavioral problems. In this process goals of public health & community health overlapped. So some readers preferred using community health D) HEALTH FOR ALL PHASE (1981-2000): Only 20 percent of people in developing countries enjoyed good health facilities. To provide good health facilities to 80 percent health for all by 2000 was pledged by members of WHO .

MODERN MEDICINE
CURATIVE MEDICINE Removal Of Disease. PREVENTIVE MEDICINE/COMMUNITY MEDICINE Prevention of disease . SOCIAL MEDICINE Study of man as social being in his total environment . FAMILY MEDICINE - Family oriented medicine or health care centered on the family as unit .

PREVENTIVE MEDICINE:
It is the science and art of
Preventing disease Prolonging life and Promoting health and efficiency groups of individuals and individuals within these groups, THROUGH INTERCEPTION OF DISEASE PROCESSES Customarily applied to healthy individuals Actions affect large numbers or population

Modern Preventive Medicine: The science and art of health promotion, disability limitation and rehabilitation

SOCIAL MEDICINE
The study of the social, economical, environmental, cultural, psychological and genetic factors which have a bearing on the health of groups of individuals and individuals in these groups; and at the same time with practical measures within the social field that may be taken to promote health, prevent disease and assist recovery of the sick. By derivation, it is the study of man as a social being in his total environment.

McKeon says In contemporary usage social medicine has two meanings:

o

One broad and ill-defined and other more restricted but precise. In the broad sense, social medicine is an expression of the humanitarian tradition in medicine and people read into it any interpretation consistent with their aspirations and interests. Thus it may be identified with care of patients, prevention of disease, administration of medical services; almost with any subject in the extensive field of health and welfare. But in the more restricted sense, social medicine is concerned with a body of knowledge embodied in epidemiology and the study of the medical needs or medical care of society.

COMMUNITY MEDICINE
A branch of medical practice that is concerned with promoting, maintaining, and when necessary, restoring the health of human communities rather than with the clinical care of individuals. From this definition, it can be inferred that the practice of community medicine requires:
A defined consumer population/ community A defined health care delivery system A comprehensive and integrated health care service. An epidemiological understanding of community health problems A management oriented approach for these problems

FAMILY MEDICINE
A field of specialization in medicine which is neither disease nor organ oriented. It is family oriented medicine of health care centered on the family as a unit from first contact to the ongoing care of chronic problems (from prevention to rehabilitation.

Family practice is horizontal practice.

Distinction B/W curative medicine & preventive medicine

Curative medicine
Preventive medicine

Panel Discussion Public Health Community Medicine Curriculum.htm

Individual

Populations

Disease Diagnosis and treatment

Health Prevention and health promotion

Modern interpretation of Winslow's definition by Beaglehole & Bonita

They identified the following essential elements of modern public health . A. Collective responsibility (public =people). B. Prime role of state in protecting & promoting the public s health . C. Partnership with the population served.

Cont .

D. Recognizing underlying socio-economic determinants of health and disease . E. Emphasis on prevention. F. Identifying & dealing with proximal risk factors. G. Multidisciplinary basis for action.

WHERE DO COMMUNITY SPECIALISTS WORK?

1. 2. 3. 4. 5. 6. Teaching ; Practice of public health at local, regional , provincial, national or international level Planning and administration of health services in institutions and government; Community oriented clinical practice with an emphasis on health promotion & disease prevention; Assessment and control of occupational & environmental health problems; Research ;

 As the scope of community medicine is vast it is not possible for every community medicine specialist to have in depth understanding of all aspects of community medicine specialty. A multi-disciplinary team having sound knowledge base on each aspect of the specialty is an essential pre-requisite for those institutions that have responsibilities of teaching and research in community medicine. Therefore every specialist particularly in academic positions should consider concentration on some aspects of subspecialties / themes of community medicine.

SUB SPECIALTIES OF COMMUNITY MEDICINE FOR TEACHING, RESEARCH & PRACTICE

There are five core subspecialties So Community Medicine Specialist is a Five Star Doctor 1. 2. 3. 4. 5. FAMILY MEDICINE HEALTH MANAGEMENT HEALTH COMMUNICATOR EPIDEMIOLOGY HEALTH ADVOCATOR

THEMES OR PROGRAMS UNDER SUB SPECIALTIES

1. Reproductive & Child Health 2. Communicable Diseases 3. Non- Communicable Diseases 4. Environmental Health

SUBTHEMES WITH IN THEMES

Reproductive & child health - focus on perinatal/ neonatal/preschool child/school health /infertility/reproductive tract diseases/ contraception. Communicable diseases- vector borne diseases(malaria), air borne (TB), sexually transmitted (HIV/AIDS). Noncommunicable diseases- nutrition(obesity/under nutrition), life styles(tobacco, physical activity)etc. Environmental health- air pollution, sanitation, occupational health etc.

Illustrated framework of subspecialty , theme & subtheme

Subspecialty
Health promotion

Theme
Non communicable diseases Communicable diseases Reproductive & child health Environmental health

Subtheme
Tobacco , nutrition etc..

Epidemiology Health management

HIV, TB , Malaria etc.. Family planning , ARI etc..

Family medicine

Air pollution , sanitation etc..

CAREER OPPORTUNITIES.
Bio statistics
State health department- Data Management Director Industry / Corporate - Director Of Clinical Trials. Federal government - Program Evaluation Analyst.

Epidemiology
Local / State Health Department - Director of Infectious / Chronic diseases Industry/ Corporate

Outcomes researcher

Federal government- CDC investigator Pharmaco epidemiologist

Public health paradigm of Emergency Medicine practice: I

Clinical practice Public education, advocacy Medical education Research, surveillance

Bernstein et al., Acad Emerg Med 1994;1:277-286

Public health paradigm of EM practice: II

Surveillance Monitoring access Clinical preventive services Policy development

Pollock et al., Ann Emerg Med 2001;38:675-683

Health services administration: Health Facilities Hospital/Managed Care State Health Dept Program Evaluation & Planning Industry/ Corporate- Information Systems Manager University- Health services Research Analyst Federal government- Policy Analyst Health education / Behavioral science: Voluntary health agencies - consumer information director Local health department- program planning & evaluation Industry / Corporate health promotion specialist Behavior scientist Administrator

Health communications :
Communications specialist Journalist

Occupational safety & Health :

Corporate medical director

Environmental health
Local health department / Environment Agency - Waste management specialist State health department / Environmental Agency- Pollution control program director Industry / Corporate Industrial hygienist Federal government EPA researcher / Administrator

Health Policy & Management :

Academic policy advisor Legislative policy advisor Management policy advisor

International & Global health:

Reproductive Health specialist International Health Specialist Tropical disease specialist

 Faculty in universities or schools for learning medicine Active participation in various National programs e.g. ICDS, EPI, UIP, CSSM, NACP, RCH etc.. Active participation in programs under supervision of WHO, UNICEF etc.. Hospital administrator Family medicine physician Office in charge of Quarantine / Isolation at airports, seaports.

All India Institute of Public Health And Hygiene Courses Offered MD (Social and Preventive Medicine)-Three years DPH- Two years Diploma in Maternity and Child Welfare-Two years Diploma in Industrial Health Two years Master of Veterinary Public Health (Open to MBBS and BVSc and AH degrees holders)- Two years Master of Engineering and Public Health (open to degree holders in Civil engineering)- 18 months Diploma in Dietetics (Also open to BHSc degree holders)- One year Diploma in Health Education (also open to graduates in any discipline including Education)- One year Diploma in Health Statistics (Also open to graduates with Mathematics or Statistics)- One year Diploma in Public Health Nursing-10 months Certificate in Public Health Nursing-13 weeks.

 Ph. D. in Health Services Ph. D in Public Health Master of healthcare Administration (MHA) M S in Clinical Research Administration Programme Master of Public Health (MPH)

Edge of community medicine specialists over physicians from other disciplines

In addition to the knowledge of basic and clinical sciences and skills common to all physicians , distinctive aspects of preventive medicine include knowledge of and competence in.  Epidemiology & biostatistics  Administration (including planning, organization, management, financing & evaluation of health programs)  Environment & occupational health.  Application of the social & behavioral factors in health.  Application of primary , secondary & tertiary preventive measures.

Yet

Perhaps never has there been more exciting time t0 pursue a career in public health.

why?

There is shortage of the community health specialists. Health services delivery systems are undergoing rapid change. Greater emphasis is being placed on health promotion and disease prevention as a means to reduce the costs of care by improving the health of our populations. These changes have created a broad array of new opportunities for professionals with advanced training in public health. Most experts agree that major advances in improvement of health over the next decades will not come from new medical findings or cures, but rather the broader and application of population- based prevention programs. As the public has become better informed about the effects of toxic wastes & pollutants on their health, greater emphasis is being placed on assuring the safety of our communities as well as worker health & safety. As a result, there is growing demand for experts in environmental health & industrial hygiene. Public health research is focusing more on women s health, & child substance abuse, & an increased emphasis is being placed on behavioral change to prevent the risk of STD s, HIV/AIDS, TB & unplanned pregnancies . Greater emphasis is also being placed on school health & the health of minority & disadvantaged populations.

Panel Discussion: Public Health / Community Medicine Curriculum

For the postgraduates, each and every institution has its own curriculum. We do not have a standardized degree or just a curriculum itself. Medical Council of India, that says it does not prescribe a curriculum but it says it will be self-directed learning, selfsustained learning, lifelong learning and it is also a planned way of learning and how the PGs acquire this learning, I leave to them, they are the best judge.

 The second mandate of Medical Council of India is that at the beginning of the PG course, it must be given to each postgraduate students in their hand as to what are the learning objectives, what methods are to be there, what contents are to be there, and ultimately the challenge is whether or not we have those stated objectives or learning objectives

curriculum is thesis-centric we have got some problem in developing the skills, which are necessary for these types of jobs the management sciences and another is the computer education Foundation course. I mean that should be more specific. Isn t it? The second is about the communities setting and the training should be in the community setting Is community Medicine person is a "Jack of all trades and a master of none. Slowly most of our things are being taken over by the clinicians Our core strengths will always be epidemiology and biostatistics. Need for brand building exercise We must have some clinics,

References :
Text book of PSM Mahajan Gupta 2nd edition Pfizer s guide to Careers in Public Health Future of academic community medicine in developing countries- Willoughby Lathem MD IJCM vol 29, No. 4(2004-10 - 2004-12) IJCM vol 30, No. 2(2003-04 - 2005-06), by DR. Rajesh kumar , HOD department of community medicine. Future of community medicine - journal of royal society of medicine. Text book of community medicine Bhaskar Rao Foundations of preventive & social medicine Dhaar & Robbani

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