⦁ MODERN MEDICINE - CURATIVE MEDICINE and PREVENTIVE MEDICINE
⦁ With the control of acute infectious diseases, the so-called modern diseases such as cancer, diabetes, cardiovascular disease, mental illness and accidents came into prominence and have become the leading causes of death in industrialized countries
⦁ So there are other factors in the etiology of the disease like social, economical, genetic , environmental and psychological factors - multi factorial causation
⦁ Pettenkofer of Munich - multi factorial causation
⦁ Curative medicine - Its primary objective is the removal of disease from the patient (rather than from the mass).
⦁ Specialisation have occurred , sub specialities have been also seen
⦁ Specialization has no doubt raised the standards of medical care, but it has escalated the cost of medical care and placed specialist medical care beyond the means of an average citizen, without outside aid or charity
⦁ Preventive medicine - applied to healthy people, customarily by actions affecting large numbers or populations. Its primary objective is prevention of disease and promotion of health.
⦁ Bacterial vacccines and antisera - removed wide spectrum of specific diseases
⦁ The introduction of tissue culture of viruses led to the development of anti-viral vaccines, e.g., polio vaccines
⦁ The eradication of smallpox (the last case of smallpox occurred in Somalia in 1977) - biggest triumph in the field of preventive medicine
⦁ Nutrition is equally important. New strategies have been developed for combating specific deficiencies as for example, nutritional blindness and iodine deficiency disorders
⦁ The recognition of the role of vitamins, minerals, proteins and other nutrients, and more recently dietary fiber emphasize the nutrition component of preventive medicine.
⦁ Then came discovery of Synthetic Insecticides - DDT, HCH, malathion and others - control vector borne diseases like malaria, leishmaniasis, plague, rickettsial diseases
⦁ Despite insecticide resistance and environmental pollution mishaps (e.g., Bhopal tragedy in India in 1984), some of the chemical insecticides such as DDT still remain unchallenged in the control of disease
⦁ Discovery of sulpha drugs, anti malarials , antibiotics, anti-tubercular and and leprosy drugs
⦁ Concept of disease eradication - used for smallpox, measles, tetanus, guinea worm, endemic goiter
⦁ "Screening" for the diagnosis of disease in its presymptomatic stage. Two most common tests in the 1930s were serologic blood test for syphilis and chest x-ray for TB.
⦁ Three levels of prevention are now recognized: primary, intended to prevent disease among healthy people; secondary, directed towards those in whom the disease has already developed ; and tertiary, to reduce the prevalence of chronic disability consequent to disease
⦁ Social medicine - European speciality
⦁ Social pioneers - Neumann and Virchow
⦁ A Chair of social medicine was set up at Oxford in 1942
⦁ Social medicine is the study of man as a social being in his total environment. Its focus is on the health of the community as a whole.
⦁ CHANGING CONCEPTS IN THE PUBLIC HEALTH -
⦁ A. Disease control phase (1880-1920)- Sanitary legislation and sanitary reforms, control of man's physical environment
⦁ B. Health promotional phase (1920-1960)- It was realized that public health had neglected the citizen as an individual, and that the State had a direct responsibility for the health of the individual.
⦁ So a new goal added to the public health goals - health of an individual such as mother and child health services, school health services, industrial health services, mental health and rehabilitation services
⦁ C.E.A. Winslow- defined public health as "the science and art of preventing disease , prolonging life and promoting health and efficiency through organized community effort".
⦁ As state had direct responsibility for the health of the individual - 2 reforms were made - (a) provision of "basic health services" through the medium of primary health centres and subcentres for rural and urban areas. (b) The second great movement was the Community Development Programme to promote village development through the active participation of the whole community and on the initiative of the community.
⦁ Lord Dawson - concept of health centres
⦁ The Bhore Committee (1946) in India had also recommended the establishment of health centres for providing integrated curative and preventive services.
⦁ C. Social engineering phase (1960-1980)-
⦁ Old diseases were gone but new diseases emerged as well like cancer, diabetes, cardiovascular diseases, alcoholism and drug addiction
⦁ These problems could not be explained by the traditional approaches to public health such as isolation , immunization and disinfection nor could be explained by germ theory of the disease ⦁ Social and behavioral aspects of disease and health were given a new priority
⦁ D. Health for all phase (1981-2000)- Most people in the developed countries, and the elite of the developing countries, enjoy all the determinants of good health - adequate income, nutrition, education, sanitation, safe drinking water and comprehensive health care. In contrast, only 10 to 20 per cent of the population in developing countries enjoy ready access to health services of any kind. Death claims 60-250 of every 1000 live births within the first year of life and the life expectancy is 30 per cent lower than in the developed countries
⦁ Against this background, in 1981, the members of the WHO pledged themselves to an ambitious target to provide "Health for All" by the year 2000, that is attainment of a level of health that will permit all people "to lead a socially and economically productive life"
⦁ MEDICAL REVOLUTION -
⦁ State of the art - new capabilities to modify and perhaps control the capacities and activities of men by direct intervention into and manipulation of their bodies and minds, viz. genetic counselling, genetic engineering, prenatal diagnosis of sex, prenatal diagnosis of genetic diseases, in vitro fertilization, the prospect of cloning (the asexual reproduction of unlimited number of genetically identical individuals from a single parent), organ transplantation, the use of artificial kidney machine, the development of an artificial heart, the practice of psychosurgery, etc.
⦁ Failure of the medicine - Despite spectacular biomedical advances and massive expenditures, death rates in the developed countries have remained unchanged; and also life expectancy.
⦁ Some critics have even described modern medicine as a threat to health. Their arguments have been based on certain facts such as:
⦁ (a) with increased medical costs has not come increased benefits in terms of health
⦁ (b) despite spectacular advances in medicine, the threat posed by certain major diseases such as malaria , schistosomiasis, leprosy, filaria, trypanosomiasis and leishmaniasis either has not lessened or has actually increased
⦁ (c) the expectation of life has remained low and infant and child mortality rates high in many developing countries, despite advances in medicine
⦁ (d) historical epidemiological studies showed that significant improvements in longevity had been achieved through improved food supplies and sanitation long before the advent of modern drugs and high technology.
⦁ (e) there is no equity in the distribution of health services, resulting in limited access to health care for large segments of the world's population
⦁ (f) modern medicine is also attacked for its elitist orientation even in health systems adapted to overcome social disparities
⦁ It is labelled as "failure of success"
⦁ Social control of the medicine - As the cost of medical care increased, two kinds of medical care came into existence - one for the rich and the other for the poor.
⦁ The gap was bridged by the charitable and voluntary agencies providing free medical care to the poor. An attitude developed that charity was worthy of man and that the benefits of modern medicine should be available to all people. A solution was to be found - it was "socialization of medicine"
⦁ Germany led the way by instituting compulsory sickness insurance in 1883
⦁ Russia was the first country to socialize medicine completely and to give its citizens a constitutional right to all health services
⦁ Socialization is a noble idea. It eliminates the competition among physicians in search of clients. It ensures social equity, that is universal coverage by health services. Medical care becomes free for the patient, which is supported by the State
⦁ "Community participation" , which, as envisaged by WHO and UNICEF is "the process by which individuals and families assume responsibility for their own health and welfare and for those of the community, and develop the capacity to contribute to their and the community's development
⦁ It was called as the "health by the people "
⦁ Family and Community Medicine - Dr. Francis Peabody, professor of medicine at Harvard, commented that specialization in medicine had already reached its apex and that modern medicine had fragmented the health care delivery system to too great a degree. He called for a rapid return of the general physician (family physician) who would give comprehensive and personalized care
⦁ Family and community medicine overlap and strengthen each other.
⦁ Family Medicine - defined as a field of specialization in medicine which is neither disease nor organ oriented. It is family oriented medicine or health care centered on the family as the unit - from first contact to the ongoing care of chronic problems (from prevention to rehabilitation). When family medicine is applied to the care of patients and their families, it becomes the specialty of family practice. Family practice is a horizontal specialty, which, like pediatrics and internal medicine, shares large areas of content with other clinical disciplines. The specialty of family practice is specially designed to deliver "primary care"
⦁ Community Medicine - successor of what was previously called as public health, community health, preventive and social medicine
⦁ defined as "that specialty 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"
⦁ HEALTH CARE REVOLUTION -
⦁ Background - social injustice , public health care needs not getting satisfied. In short, there has been a growing dissatisfaction with the existing health services and a clear demand for better health care.
⦁ Health for all - 30th world health assembly in may 1977 - main motive - that "the main social target of governments and WHO in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. "
⦁ elimination of malnutrition, ignorance, disease, contaminated water supply, unhygienic housing, etc
⦁ Primary Health Care - new approach to health care, which integrates at the community level all the factors required for improving the health status of the population. consists of at least 8 elements called as "essential health care"
⦁ Primary health care is available to all people at the first level of health care. It is based on principles of equity, wider coverage, individual and community involvement and intersectoral coordination.
⦁ Global strategy for Health for All by the 34th World Health Assembly in 1981.
⦁ Deprofessionalisation of Medicine - Laymen have come to play a prominent role in the delivery of health care. While the physician still holds his unique position in the field of health care in general, the participation of a new cadre of health workers (e.g. , community health workers, anganwadi workers, multipurpose workers, practitioners of indigenous medicine, social workers) with relatively little training and support have been considered and tried to provide health care.
⦁ The medical man can no longer restrict himself to his traditional role as diagnoser of ailments, prescriber of pills and potions, and exciser of lumps . He has acquired new roles - being an educator, case-finder, preventer, counsellor and an agent of social change.
⦁ Millenium Development Goals - to reduce poverty and hunger, and to tackle ill-health, gender inequality, lack of education, access to clean water; and environmental degradation
⦁ In September 2000, representatives from 189 countries met at the Millennium Summit in New York to adopt the United Nations Millennium Declaration.
⦁ Sustainable Development Goals - In September 2015, the United Nations General Assembly adopted the new development agenda Transforming our world : the 2030 agenda for sustainable development.
⦁ Comprising 17 Sustainable Development Goals (SDGs), the 2030 Agenda integrates all three dimensions of sustainable development (economic, social and environmental) around the themes of people, planet, prosperity, peace and partnership.
⦁ The SDGs recognize that eradicating poverty and inequality, creating economic growth and preserving the planet are inextricably linked, not only to each other, but also to population health.
⦁ Health is centrally positioned within the 2030 Agenda, with one comprehensive goal - SDG 3 : "Ensure healthy lives and promote well-being for all at all ages"; and explicit links to many of the other goals.
⦁ SDG 3 includes 13 targets covering all major health priorites.The target for universal health coverage is key to the achievement of all other targets and the development of strong resilient health system.
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