Essentials of Community Medicine: A Practical Approach Lalita D Hiremath, Dhananjaya A Hiremath
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Present Health StatusChapter 1

Chapter Outline
  • ❖ DISEASE BURDEN
  • ❖ REASONS FOR HIGH DISEASE BURDEN IN INDIA
  • ❖ COMMUNICABLE DISEASES
  • ❖ CHRONIC NONCOMMUNICABLE DISEASES AND CONDITIONS
  • ❖ MATERNAL AND CHILD HEALTH
  • ❖ NOTIFIABLE DISEASES
 
DISEASE BURDEN
It has been estimated that the disease burden of the people of India is one of the highest in the world (Table 1.1). We have a triple burden of infectious diseases. Firstly, we have those infectious diseases that are prevalent worldwide and for which specific preventive measures are yet not available. Secondly, we have infectious diseases that are prevalent because of insufficient public health measures. Thirdly, we have infectious diseases perpetuated by the prevalence of vectors (hematophagous arthropods) as well as vertebrate fauna, the ecological determinants of which are given due to our geoclimatic features.
 
REASONS FOR HIGH DISEASE BURDEN
  1. Poor economy of the country
  2. Maldistribution of country resources
  3. Poor governance and management to utilize resources appropriately
  4. Poor people participation.
    Table 1.1   Ten leading causes of burden of disease, world, 2004 and 2030
    2004 Disease or injury
    As % of total DALYs
    Rank Rank
    As % of total DALYs
    2030 Disease or injury
    zoom view
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  5. Poor level of literacy of the people
  6. Geographical characteristics of the country for certain diseases like malaria, filaria, etc.
  7. Poor political commitment
  8. Poor policy
  9. Poor scientific development
  10. Religious belief system and cultural practices of the population.
 
COMMUNICABLE DISEASES
About 17 percent of all deaths and about 21 percent of all illnesses are due to communicable diseases. The major problems continue to be tuberculosis, filariasis, leprosy, malaria, diarrheal diseases and malnutrition.
Among viral diseases smallpox was eradicated in 1980. Measles continues to be rife frequency in occurrence, and so is viral hepatitis. Since 1973, the country has been experiencing large scale outbreaks of Japanese encephalitis. Dengue fever is also emerging as another health problem.
Among bacterial diseases meningococcal meningitis has shown a substantial increase. Cholera has significantly declined, but the other waterborne diseases (e.g. acute diarrheas, dysentery and enteric fever) have not abated. Half the world's tuberculosis patients are in India accounting for 14 million cases of which in the world, estimated to be 0.6 million. Tetanus and Diphtheria are not yet under control.
The country has one-third of leprosy cases. Among parasitic diseases, Malaria and Kala-azar have staged a comeback. During 1995, 3 million cases of malaria and 22,000 cases of Kala-azar were reported. About 420 million people are estimated to be living in known endemic areas of Filariasis.
Intestinal parasites such as ascariasis, hookworms, giardiasis and amoebiasis are widely prevalent. STDs are on the increase.
 
CHRONIC NONCOMMUNICABLE DISEASES AND CONDITIONS
Noncommunicable diseases such as hypertension, diabetes, cancer, road accidents, alcohol drug abuse and mental health problems are slowly emerging as health problems. One reason for this appears to be changes in lifestyle and growing stresses of urban life.
The Table 1.2 shows the percentage (approximately) of major causes of all deaths in developing countries.
 
Nutritional Deficiencies
Nutritional deficiencies are widespread and include protein energy malnutrition, vitamin deficiency, vitamin B complex deficiency, nutritional anemia and iodine-deficiency disorders. Undernutrition affects millions 3of people. In 1992, about 30 percent of babies were born with birth weight of less than 2.5 kg.
Table 1.2   The percentage (approximately) of major causes of all deaths in developing countries
Case
Years
1985
2000
Infections
35
25
Neoplasm
7
10
Circulatory diseases
20
30
Injuries
8
6
Recent trends with regard to nutritional status of women and children in India have been positive and modest. The improvement has been marked with respect to the prevalence of ‘severe malnutrition’. Even with respect to moderate undernutrition modest improvements in anthropometry and birth weight have been noticeable even amongst the poor.
 
MATERNAL AND CHILD HEALTH
By virtue of the large group (Women 22% Children 38% together constitute 60%) of total population and also vulnerable or special risk group mother and children are the major consumer of health services.
Tables 1.3 and 1.4 show the poor status of MCH (Maternal and Child Health).
 
Burden of Occupational Diseases and Injuries
There are 100 million occupational injuries causing 0.1 million deaths in the world according to WHO (Leigh et al 1999). It is also estimated that in India 17 million occupational nonfatal injuries (17% of the world) and 45,000 fatal injuries (45% of the total deaths due to occupational injuries in world) occurs each year. Out of 11 million cases of occupational diseases in the world 1.9 million cases (17%) are contributed by India and out of 0.7 million deaths in the world 0.12 (17%) is contributed by India.
Table 1.3   Health facilities in India
India
Population 2001 (Million)
1028.61
Projected population 2010 (Million)
1176.71
Health care infrastructure
Community health centers
42762
Primary health centers
234582
Subcenters
1460362
Total FRUs
18132
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India
CHCs owned building
38822
PHCs owned building
197062
SCs owned building
788032
Manpower status
Total allopathic doctors
7251903
Total allopathic doctors in Govt
848523
Total dentist
730573
Total dentist in govt sector
32333
Total ayurvedic doctors
4584183
Total registered ANMs
5492923
Total ANMs in govt
1535682
Total registered GNMs
9715743
Total registered LHVs
514973
Total specialist at CHCs
42792
MBBs doctors at PHCs
243752
Health care indicators
Doctor population ratio (per 1000)
0.633
Doctor nurse ratio
0.463
Nurse population ratio (per 1000)
1.373
Bed population ratio
0.874
Population per subcenter ratio
78382
Population per PHC
487992
1 Census of India 2RHS-08 3 NPH-08 4CBHI
Table 1.4   Health status in India
Infants mortality rate
532
Maternal mortality ratio
2542
Total fertility rate
2.72
Crude birth rate
22.82
Crude death rate
7.42
Life expectancy
66.91
Under 5 mortality rate
74.33
Total fertility rate
2.63
ANC-3 check ups (%)
523
I and FA Tab. received for 90 days %
233
Two TT Inj. received in last preg %
723
Birth in medical institutions (%)
493
BCG (%)
783
Polio 3 doses (%)
783
DPT3 (%)
553
Measles (%)
593
1 Census of India 2 NHP-08 3 SRS-08
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Clinical Diagnosis and Community Diagnosis (Table 1.5)
Table 1.5   Comparative model of clinical diagnosis and community diagnosis
Clinical diagnosis
Community diagnosis
• Sick patient
Sick community
• Patient decides to consult doctor
Community feels the need for consulting professionals
• Visits doctor
Professions and community interaction
• Doctor takes history and symptomology
Studies community history, hospital record, birth, death, notification analysis
• Provisional diagnosis
Community provisional diagnosis, (Identify community problems)
• Decides which system to examine and
Decides what type of exploration or what type of investigations to be performed studies to be conducted in the community
• Carry out clinical examination and investigations
Carry health surveys, screening for diseases surveillance
• Scrutiny, analysis and interpretation clinical examination and laboratory results
Scrutiny, analysis and interpretation of data
• Arrives at clinical diagnosis
Makes community diagnosis
• Decides treatment and advice
Decide on community treatment or community action on priorities.
• Administers the treatment and give advices
Plans and implements community service and program
• Monitor of follow-up of the patient (Symptomatic improvement, etc)
Monitor community change, reduction in morbidity, mortality, etc. (Evaluation)
• If no improvement change the treatment regimen
If no improvement, change or modify plan of action
 
NOTIFIABLE DISEASES
A disease that, by statutory requirements, must be reported to the public health authority in the pertinent jurisdiction when the diagnosis is made. Following are the notifiable diseases:
  1. Lead poisoning or its sequelae.
  2. Lead tetraethyl poisoning to its sequelae.
  3. Phosphorus poisoning or its sequelae.
  4. Mercury poisoning or its sequelae.
  5. Manganese poisoning or its sequelae.
  6. Arsenic poisoning or its sequelae.
  7. Poisoning by nitrous fumes.
  8. Carbon bisulfite poisoning.
  9. Benzene and its derivatives poisoning or its sequelae.
  10. Chrome ulceration or its sequelae.
  11. Anthrax.
  12. Silicosis.
  13. Poisoning by halogens or its derivatives of hydrocarbons.
  14. Pathological manifestation due to radium, radioactive substances, or X-rays.
  15. Primary epitheliomatous cancer of the skin.
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  16. Toxic anemia.
  17. Toxic jaundice due to poisonous substances.
  18. Oil acne or dermatitis due to mineral oil or its derivatives in any form.
  19. Byssinosis.
  20. Asbestosis.
  21. Occupational or contact dermatitis caused by direct contact with chemical or paints. It could be primary irritants or allergic sensitizers.
  22. Noise induced hearing loss.
  23. Beryllium poisoning.
  24. Carbon monoxide.
  25. Coal miner's pneumoconiosis.
  26. Phosgene poisoning.
  27. Occupational cancers.
  28. Isocyanates poisoning.
  29. Toxic nephritis.