Evolution of Social medicine in India.
This history dates back
(at least) to the early nineteenth century when the systematic study of the
relationships between society, disease, and medicine began in earnest. This
study—and the forms of medical practice derived from it—became known as “social
medicine.” Over time the term “social medicine” took on varied meanings as it
was adapted to differing societies and diverse social conditions. Nonetheless,
certain common principles underlie the term:
·
Social and
economic conditions profoundly impact health, disease, and the practice of
medicine.
·
The health of
the population is a matter of social concern.
·
Society should
promote health through both individual and social means.
Social conditions
contribute to ill health. This was described as early as the 19th century by
Rudolf Virchow, generally considered the founder of social medicine.
Social medicine, an
approach to the prevention and treatment of disease that is based on the study
of human heredity, environment, social structures, and cultural values.
It is the field of
medicine that studies the impact of the collective behavior of organized
society on individuals belonging to various, often disadvantaged, subgroups
within the society. This is found in Engel’s phenomenon of Homelessness,
Latchkey children, Supermom. Socialized medicine.
It is a specialized
field of medical knowledge concentrating on the social, cultural, and economic
impact of medical phenomena. The field of social medicine seeks to: understand
how social and economic conditions impact health, disease and the practice of
medicine and foster conditions in which this understanding can lead to a
healthier society.
This type of study
began formally in the early 19th century. The Industrial Revolution and the
subsequent increase in poverty and disease among workers raised concerns about
the effect of social processes on the health of the poor.
Prominent figures in
the history of social medicine include Rudolf Virchow, Salvador Allende, and
more recently Paul Farmer and Jim Yong Kim.
More specifically, Farmer et al. (2006) state that "Biosocial understandings of medical phenomena [such as the social determinants of health] are urgently needed". Paul Farmer's view is that modern medicine is focused at the molecular level, and there is a "gap" between social analysis and everyday clinical practices Moreover, Farmer, Nizeye, Stulac and Keshavjee (2006) view social medicine with increasing importance as scientific inquiry is increasingly "desocialized". The latter refers to "...a tendency to ask only biological question about what are in fact biosocial phenomena.
The field of social
medicine is most commonly addressed today by public health efforts to
understand what are known as social determinants of health.
Social medicine is
distinguished from medico biological and clinical disciplines that study
healthy and diseased states of the body.
Social medicine is
closely related to the social sciences, including political economy, sociology,
demography, and the general theory of administration. It concentrates primarily
on social conditions and studies the interrelationships between social and
biological factors in medicine. Evaluations are made primarily on the basis of
statistics.
Social medicine also
utilizes evaluations made by specialists in various fields, experiments,
models, questionnaires, and the historical method.
The bases of social
medicine are associated with the study of occupational diseases, medico
topographical data, and public‐health statistics. In
the late 18th century the use of J. P. Frank’s system of medical police
promoted the state regulation of public health. In the 19th century the
development of social medicine was associated with the rise of capitalism and
with bourgeois‐democratic revolutions. In Great Britain, France,
Germany, and other countries data were gathered on how working and living
conditions affected the health of workers. Statistical methods were used in
making evaluations, and attempts were made to substantiate scientifically
public‐health measures. The term “social medicine” was
introduced at this time.
From the late 18th
century until the 1870’s specific issues were presented in medical‐ police and social‐medicine
courses in various countries. At the turn of the 20th century chairs of social
medicine were established, and independent courses in social medicine and
social hygiene were given by A. V. Korchak‐Chepurkovskii
in Kiev (from 1906), A. I. Shingarev in St. Petersburg (from 1908), L. Teleky
in Vienna (from 1909), and A. Grotjahn in Berlin (from 1912). The subsequent
development of social medicine proceeded under the influence of social
democratic ideas and the class struggle of the proletariat in capitalist
countries.
The organizational
basis of social medicine is the Soviet system of public health, which is
directed toward the socioeconomic transformation of society and the elimination
of social roots generating diseases and which makes available state measures
for the protection of the health of citizens. It is under socialist conditions
that social medicine is best able to elaborate the scientific bases for
therapeutic preventive measures fostering the harmonious physical and spiritual
development of man and promoting maximum life expectancy. The development of
social medicine and the introduction of preventive medicine into medical
practice and into the system of medical education were promoted by the
activities of the sub departments of social medicine created in the First
Moscow State University (N. A. Semashko, 1922), the Second Moscow State
University (Z. P. Solov’ev, 1923), and the State Institute of Social Medicine
(A. V. Mol’kov, 1923). Sub departments of social medicine were later created in
all higher medical institutions.
The leading scientific
center on social medicine and public‐health
administration is the N. A. Semashko All‐Union
Scientific Research Institute of Social Medicine and the Organization of Public
Health of the Ministry of Public Health of the USSR (Moscow). Research is being
conducted in the USSR on theoretical issues of social medicine and the
organization of public health, on social conditions and the health of the
population, and on the scientific foundations of the economics and planning of
public health. An automated public‐health
planning and administration system is being developed, and the scientific
foundations of the organization of medical care and the training and education
of the population in social medicine are under study. Social medicine is part
of the curriculum at
several institutions outside the USSR, including the Institute of Social
Hygiene and Health Organization of the People’s Republic of Bulgaria, the
Academy for Advanced Training of Physicians in the German Democratic Republic,
and the Institute of Social Medicine and Organization of Public Health of the
Czechoslovak Socialist Republic. All‐Union,
republic, and local societies of hygienists and public‐health physicians have groups specializing in social
medicine. International organizations that function in the area of social
medicine include the World Health Organization (founded 1948), the
International Medical Association for the Study of Living Conditions and Health
(founded 1951), and the European Association of Social Medicine (founded 1955).
In the USSR, social
medicine is taught at medical institutes by departments of therapeutics,
pediatrics, and public health and hygiene under the control of sub departments
of social medicine and public‐health organizations
(from 1941 to 1966— sub‐departments of public‐health organizations). Outside the USSR it is
controlled by sub departments of social medicine, public‐health organizations, and community health
protection.
The most important
domain of social medicine is the culture itself. Health professionals and
institutions have their own cultures that also go beyond clinical interactions.
Health systems and health research both contain agendas, prejudices, and
beliefs that can lead to certain perspectives being favored as the most
legitimate. Understanding the culture of medicine is essential to understanding
health professionals' attitudes toward illness, patients, and treatments
Preventive and Social Medicine
(PSM) is relatively a new branch of medicine. It is often considered synonymous
with Community Medicine, Public Health, and Community Health in India. All
these share common ground, i.e. prevention of disease and promotion of health.
In short, PSM provides comprehensive health services ranging from preventive,
promotive, curative to rehabilitative services. The importance of the specialty
of PSM has been very well recognized and emphasized repeatedly from grass root
to international levels, not only in health sector but in other related sectors
too. Whereas clinical specialties look after individual patient, PSM has to
think and act in terms of whole community. The scope of medicine has expanded
during the last few decades to include not only health problems of individuals,
but those of communities as well. If we want to achieve Health for All,
Community Medicine will definitely be the key factor during the next
millennium.
The following points
elaborate the evolution of social medicine:
The industrial revolution of the 18th century while bringing affluence also brought new problems ‐ slums, accumulation of refuse and human excreta, overcrowding and a variety of social problems. Frequent outbreaks of cholera added to the woes Chadwick’s report on ‘The Sanitary Conditions of Laboring Population (1842)’ focused the attention of the people and Government on the urgent need to improve public health. Filth and garbage were recognized as man’s greatest enemies and it lead to great sanitary awakening bringing Public Health Act of 1848 in England, in acceptance of the principle that the state is responsible for the health of the people. The act was made more comprehensive in 1875 when Public Health Act 1875 was enacted. The public health movement in USA followed closely the English pattern. The organized professional body, American Public Health Association was formed in 1872. The Indian Public Health Association was formed in 1958.
Public Health is
defined as the process of mobilizing local, state, national and international
resources to solve the major health problems affecting communities and to
achieve Health For All by 2000 AD.
Many different
disciplines contributed to the growth of Public Health; physicians diagnosed
diseases; sanitary engineers built water and sewerage systems; epidemiologists
traced the sources of disease outbreaks and their modes of transmission; vital
statisticians provided quantitative measures of births and deaths; lawyers
wrote sanitary codes and regulations; public health nurses provided care and
advice to the sick in their home; sanitary inspectors visited factories and
markets to enforce compliance with public health ordinances; and administrators
tried to organize everyone within the limits of the health departments budgets.
Public Health thus involved Economics, Sociology, Psychology, Law, Statistics,
and Engineering as well as biological and clinical sciences. Soon another
important and emerging branch of medicine i.e., Microbiology became an integral
part of Public Health. Public Health during the 19th Century was around
sanitary regulations and the same underwent changes
Preventive Medicine
developed as a branch of medicine distinct from Public Health. By definition,
preventive medicine is applied to ‘healthy’ people, customarily by actions
affecting large numbers or populations. Its primary objective is prevention of
disease and promotion of health. It got a firm foundation only after the
discovery of causative agents of diseases and the establishment of the germ
theory of disease. The development of laboratory methods for the early
detection of disease was a further advance.
Social Medicine has
varying meanings attached to it. By derivation, it is the study of man as a
social being in his total environment. It may be identified with care of
patients, prevention of disease, administration of medical services; indeed
with almost any subject in the extensive field of health and welfare. In short,
social medicine is not a new branch of medicine but rather a new orientation of
medicine to the changing needs of man and society.
Community Medicine has
been 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.
Decades old concept of
health care approach has experienced a dramatic change. Today health is not
merely an absence of disease; it is related to quality of life instead. Health
is considered a means of productivity. Thus health development is essential to
socio‐economic development as a whole. Since health is an
integral part of development, all sectors of society have an effect on health.
Scope of medicine has extended from individual to community. Study of health
and disease in population is replacing study of disease in man. Germ theory of
disease gave place to
newer concepts ‐ multi‐factorial
causation. Social and behavioral aspects of the disease have been accorded a
new priority. Contemporary medicine is no longer solely an art and science for
the diagnosis and treatment of diseases. It is also the science for the
prevention of disease and promotion of health. Today technical sophistication
of modern medicine is not an answer to everyday common ailments of the vast
poor in the country. Appropriate technology and cheaper interventions like Oral
Rehydration Solution (ORS), immunization, etc are increasingly being applied as
life saving measures and for disease prevention in community health care.
Physicians’ role is no longer confined to diagnosing and treating those who
come to the clinic. He is also responsible for those who need his service but
cannot come to the clinic. Health of the people is not only the concern of
health care providers. It is the responsibility of the community also to
identify and solve their own health problems through their active
participation.
All these changes in
concept and ideas of health and health care system are embodied in community
health care. The spate of new ideas and concepts, for example, increasing
importance given to social justice and equity, recognition of crucial role of
community participation called for the new approaches to make medicine in the
service of humanity more effective.
Alma‐Ata declaration in 1978 specified that Primary
Health Care approach was the way of achieving the goal of Health For All by
2000 AD. Primary Health Care approach stressed that “essential health care
should be made universally accessible to individuals and acceptable to them,
through their full participation and at a cost the community and the country
can afford”.
The Public Health
administration in India actually started in 1869 with the appointment of a
Sanitary Commission. The first Municipal Act was passed in 1884 in Bengal. But
in the Indian context J. P. Grant had visualized in 1939 that foreign models
could not be suited for First Doctor Intervention or for Primary Health Care.
His recommendations were also incorporated in Bhore Committee Report 1946, for
building Community Physicians. The Bhore Committee’s Report laid the foundation
of modern public health care in India.
On the recommendations
of Medical Education Conference in 1955, departments of Preventive and Social
Medicine were established in Medical colleges all over the country. The
experimental learning of our predecessors and Gurus provided the foundation and
led to growth and expansion of the frontiers of the subject of Community
Medicine. It has today evolved as a field of learning that contributes
immensely to the progress and development of societies, more significantly in
developing nations like India. The professionals of Community Medicine have a
major responsibility to shoulder i.e., to work for the health and well being of
the people of India and contribute to education and production of basic
doctors, well versed with handling community health problems. The objective of
medical education is to produce a basic doctor who is competent to give
comprehensive health care to individual, family and community. We need to bring
about many changes, reforms in current medical education for achieving the
desired objective.
These departments have
teaching / training, service and research components. But initially more
emphasis was placed on teaching / training aspect. Beyond 1975, faculty members
of Community Medicine were enriched with the field experiences in training,
monitoring and evaluation with active participation in various National
Programmes like ICDS (Integrated Child Development Scheme), EPI (Expanded
Program on Immunization), UIP (Universal Immunization Program), CSSM (Child
Survival and Safe Motherhood programme), NACP (National AIDS Control Program),
RCH (Reproductive and Child Health programme) and have shared their experiences
with the District / State / National Health Programme managers and also
translated their experiences in Undergraduate and Postgraduate training and
teaching.There are variations in teaching / training in Preventive and Social
Medicine in different states of India which reflects the cultural diversity and
varying needs of the local community. The research component has been a very
poorly developed component of PSM so far mainly because of scarcity of funds.
Medical colleges have
the primary function of imparting undergraduate medical education. These
colleges form the majority of institutions in India, which provide professional
postgraduate qualification in Public Health. A school of public health like All
India Institute of Hygiene and Public Health, Calcutta, especially established
for the purpose without the responsibility of undergraduate medical education
is an exception.
It is noted that many
medical colleges are unable to have good community‐oriented, field‐
based programmes for demonstration and participatory education of the
undergraduates. Medical colleges, by and large, remain isolated from health
care system and play very limited role in public health services. However,
desirable and positive changes through various approaches are taking place in
the medical education system all over the world and in our country to enable it
to stand up to the expectations of the country in the context of its overall
social‐economic‐health
development process e.g., by reorientation of curriculum, by community‐based integrated teaching or by making medical
colleges assume direct responsibility in providing health care, etc.
It is noted that many
medical colleges are unable to have good community‐oriented, field‐
based programmes for demonstration and participatory education of the
undergraduates. Medical colleges, by and large, remain isolated from health
care system and play very limited role in public health services. However,
desirable and positive changes through various approaches are taking place in
the medical education system all over the world and in our country to enable it
to stand up to the expectations of the country in the context of its overall
social‐economic‐health
development process e.g., by reorientation of curriculum, by community‐based integrated teaching or by making medical
colleges assume direct responsibility in providing health care, etc.
It is noted that many
medical colleges are unable to have good community‐oriented, field‐
based programmes for demonstration and participatory education of the
undergraduates. Medical colleges, by and large, remain isolated from health
care system and play very limited role in public health services. However,
desirable and positive changes through
various approaches are
taking place in the medical education system all over the world and in our
country to enable it to stand up to the expectations of the country in the
context of its overall social‐economic‐health development process e.g., by reorientation of
curriculum, by community‐based integrated
teaching or by making medical colleges assume direct responsibility in
providing health care, etc.
In the field of Public
Health & Preventive Medicine, tremendous changes have taken place, but
greater changes can be anticipated in the coming decades. Ideas and policies
cannot be static and planning must have enough flexibility to cope with the
fast‐changing world of science and technology, of
industrialization and urbanization. It is obvious that new horizons and super‐specialties are fast emerging in Preventive and
Social Medicine, like Epidemiology, MCH (Maternal and Child Health), IEC
(Information Education Communication), Health Management, Health Economics,
Nutrition, Demography, Health System Research, Environmental Health, etc.
Current developments in Information Technology will certainly alter the face of
Preventive and Social Medicine in the coming future.
In the field of Public Health
& Preventive Medicine, tremendous changes have taken place, but greater
changes can be anticipated in the coming decades. Ideas and policies cannot be
static and planning must have enough flexibility to cope with the fast‐changing world of science and technology, of
industrialization and urbanization. It is obvious that new horizons and super‐specialties are fast emerging in Preventive and
Social Medicine, like Epidemiology, MCH (Maternal and Child Health), IEC
(Information Education Communication), Health Management, Health Economics,
Nutrition, Demography, Health System Research, Environmental Health, etc.
Current developments in Information Technology will certainly alter the face of
Preventive and Social Medicine in the coming future.
There are many
challenges in the field of Public Health. One of the challenges, which are
successfully met, is “Eradication of Smallpox”. This is a wonderful achievement
which all of us are proud of. Another disease, which is successfully eliminated,
is Guinea worm disease. There were setbacks in some of the programmes like
Malaria, Tuberculosis that made us rethink and re‐modify
the strategies and re‐implement these
national health programmes. As we are able to control some diseases, there will
be new emerging as well re‐emerging diseases. This
faculty has to be remain alert all the time and prepared for meeting the new
challenges
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