Mahajan & Gupta Textbook of Preventive and Social Medicine Rabindra Nath Roy, Indranil Saha
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General

Evolution of Preventive and Social Medicine1

Preventive and Social Medicine is comparatively a newcomer among the academic disciplines of medicine. Previously it was taught to medical students as hygiene and public health. This name was later changed to preventive and social medicine when it was realized that the subject encompassed much more than merely the principles of hygiene and sanitation and public health engineering. The name preventive and social medicine emphasizes the role of: (a) disease prevention in general through immunization, adequate nutrition, etc. in addition to the routine hygiene measures, and (b) 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.
 
Historical Background
During last 150 years, there have been two important “revolutions”. The industrial revolution in 1830 was associated with the discovery of steam power and led to rapid industrializations, resulting in concentration of wealth in the cities and, consequently, migration from rural to urban areas. The net result was that on the one hand the villages were neglected and, on the other, the towns and cities witnessed rapid haphazard expansion, often leading to creation of urban slums. These changes brought in their wake and more complex health problems in rural as well as urban areas which ultimately led to development of the concept of public health. The social revolution occurred around 1940, during the Second World War. The social revolution brought into force the concept of ‘Welfare State’. It envisaged the total well being of man, paying major attention to the forgotten majority living in the villages. It was aimed at fighting the three enemies of man—poverty, ignorance and ill-health on a common platform. This followed the realization that health was not possible without improvement in economic condition or education and vice versa.
Among the developing countries, India gave a lead for bringing about the total well being of rural people by instituting the remarkable Community Development Program (1951). For intensive all-round development, the country was divided into Community Development Blocks in which ill-health was to be fought through the agency of primary health centers as recommended by the Bhore Committee. It may be mentioned that the concept of public health was fairly well developed in ancient Indian. Adequate proof of community health measures adopted during Harappa Civilization as far as 5000 years ago has been found in the old excavations at Mohenjo-Daro and at Lothal near Ahmedabad in the form of soakpits, cesspools and underground drainage.
 
Public Health, Preventive Medicine, Social Medicine and Community Medicine
Traditionally, a young man planning to enter the medical college has in mind the picture of a patient in agony, in relieving whose suffering by medicines he considers himself to be amply rewarded. He always thinks of alleviating the suffering of a patient but rarely about the prevention of such suffering at the level of the individual patient, his family or his community. No doubt he has to play a very important role in meeting the curative needs of society but that is not all. The community in the past has felt satisfied with that curative role. But now the developing society, in India and elsewhere, expects much more from the doctor, and the people are gradually becoming more and more conscious of their health needs. These varied expectations are reflected in the fact that the subject has been practised in the past under different names as discussed below.
 
Public Health
It was defined by Winslow (1851) as the science and art of preventing disease, prolonging life and promoting 2health 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.1
 
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”.2 Broadly, one could state that community medicine, while encompassing the broad 3scope 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, as described later in Chapter 28, 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.
Some milestones and history of public health:
References
  1. King, Maurice. National Medical Journal of India, 1992;5:189–90.
  1. Last JM. A Dictionary of Epidemiology. Oxford University Press,  London:  1983.