UNIT-1

INTRODUCTION TO COMMUNITY
MEDICINE
SANITARY AWAKENING

Dr.P.KARNAN
PROFESSOR
 INTRODUCTION
 The nineteenth century marked a great advance in public health. "The great sanitary
awakening" (Winslow, 1923) the identification of filth as both a cause of disease
and a vehicle of transmission and the ensuing embrace of cleanliness was a central
component of nineteenth-century social reforms.

 Sanitation changed the way society thought about health. Illness came to be seen as
an indicator of poor social and environmental conditions, as well as poor moral and
spiritual conditions.

 Cleanliness was embraced as a path both to physical and moral health. Cleanliness,
piety, and isolation were seen to be compatible and mutually reinforcing measures
to help the public resist disease. At the same time, mental institutions became
oriented toward "moral treatment" and cure.
 INTRODUCTION
• The Great sanitary awakening:

 The nineteenth century marked a great advance in public health. "The great sanitary
awakening" (Winslow, 1923)—the identification of filth as both a cause of disease
and a vehicle of transmission and the ensuing embrace of cleanliness was a central
component of nineteenth-century social reforms.

 Sanitation changed the way society thought about health. Illness came to be seen as
an indicator of poor social and environmental conditions, as well as poor moral and
spiritual conditions. Cleanliness was embraced as a path both to physical and moral
health.
 Sanitation also changed the way society thought about public responsibility for citizens'
health. Protecting health became a social responsibility. Disease control continued to focus
on epidemics, but the manner of controlling turned from quarantine and isolation of the
individual to cleaning up and improving the common environment.

 And disease control shifted from reacting to intermittent outbreaks to continuing measures
for prevention. With sanitation, public health became a societal goal and protecting health
became a public activity.

 With the increasing urbanization of the population in the nineteenth century, filthy
environmental conditions became common in working class areas, and the spread of
disease became rampant.

 In London, for example, smallpox, cholera, typhoid, and tuberculosis reached

unprecedented levels. It was estimated that as many as 1 people in 10 died of smallpox.
More than half the working class died before their fifth birthday.
 Edwin Chadwick, a London lawyer and secretary of the Poor Law Commission in
1838, is one of the most recognized names in the sanitary reform movement. Under
Chadwick's authority, the commission conducted studies of the life and health of the
London working class in 1838 and that of the entire country in 1842.

 The report of these studies, General Report on the Sanitary Conditions of the
Labouring Population of Great Britain, "was a damning and fully documented
indictment of the appalling conditions in which masses of the working people were
compelled to live, and die, in the industrial towns and rural areas of the Kingdom."
(Chave, 1984) Chadwick documented that the average age at death for the gentry was
36 years; for the tradesmen, 22 years; and for the labourers, only 16 years. (Hanlon
and Pickett, 1984) To remedy the situation, Chadwick proposed what came to be
known as the "sanitary idea."
 His remedy was based on the assumption that diseases are caused by
foul air from the decomposition of waste. To remove disease,
therefore, it was necessary to build a drainage network to remove
sewage and waste.

 Further, Chadwick proposed that a national board of health, local

boards in each district, and district medical officers be appointed to
accomplish this goal. (Chave, 1984).

 Although the specific mechanisms of diseases were still poorly

understood, collective action against contagious diseases proved to be
successful. For example, cholera was known to be a waterborne
disease, but the precise agent of infection was not known at this time.
 The sanitary reform movement brought more water to cities in the mid-
nineteenth century, through private contractors and eventually through
reservoirs and municipal water supplies, but its usefulness did not depend
primarily on its purity for consumption, but on its availability for washing and
fire protection. (Blake, 1956).
 DISCOVERY OF BACTERIA
 Antoni van Leeuwenhoek (1632-1723), a cloth merchant from Belgium, afforded
humanity a glimpse into a new world: using microscopes he had built himself, he
studied pond and rainwater in 1675, discovering what he described as little animals
(“animalcula”) protozoa and bacteria.

 Later, he also observed microorganisms in human saliva and dental plaque. It was
apparently a life-altering experience: from then on, Leeuwenhoek rubbed his teeth with
salt and killed bacteria by gargling with vinegar.
  BACTERIA IN THE FOCUS OF MEDICINE

 It was not until 1847/1848 that surgeon Ignaz Semmelweis (1818-1865) managed to
prove that disinfection could contain the spread of disease. He instigated a policy requiring
all physicians in the maternity clinic at the General Hospital in Vienna to wash their hands
with chlorinated lime before each examination. The mortality rate then fell from up to 30
% to just 1.3 %.

 Physician Robert Koch (1843-1910) was the first to conduct a systematic search for the
microorganisms responsible for diseases. His discovery of the tuberculosis pathogen
(Mycobacterium tuberculosis) finally proved the correlation.

 The research work of Louis Pasteur (1822-1895) revealed the bacteriological roots of
fermentation and decay. In addition, he also developed his eponymous pasteurization
process, in which food could be disinfected and preserved by briefly heating it.

 Scottish surgeon Joseph Lister (1827-1912) began successfully using phenol to disinfect
wounds prior to operating.
Antoni van Leeuwenhoek (1632-1723) is deemed to be the discoverer of
bacteria
 Discovery of viruses
 The concept of a virus as a distinct entity dates back only to the very late 1800s. Although the
term had been used for many years previously to describe disease agents, the word “virus” comes
from a Latin word simply meaning “slimy fluid”.

 The invention that allowed viruses to be discovered at all was the Chamberl and Pasteur filter.

 This was developed in 1884 in Paris by Charles Chamberland, who worked with Louis
Pasteur. It consisted of unglazed porcelain “candles”, with pore sizes of 0.1 – 1 micron (100 -
1000 nm), which could be used to completely remove all bacteria or other cells known at the
time from a liquid suspension.

 Though this simple invention essentially enabled the establishment of a whole new science –
virology - the continued development of the discipline required a string of technical
developments, which we will highlight.
 As the first in what was to be an interesting succession of events, Adolf
Eduard Mayer from Germany, publishing in 1886 on work done in Holland
from 1879,

 showed that the “mosaic disease” of tobacco - or “mozaïkziekte”, as he named

it in his paper - could be transmitted to other plants by rubbing a liquid extract,
filtered through paper, from an infected plant onto the leaves of a healthy
plant.

 However, he came to the erroneous conclusion that it must be a bacterial

disease.
 The Dutch scientist Martinus Beijerinck in 1898 reported similar experiments with
bacteria-free filtered extracts, but made the conceptual leap and described the
agent of mosaic disease of tobacco as a “contagium vivum fluidum”, or contagious
living fluid, because he was convinced the infectious agent had a liquid nature.

 The extract was completely sterile, could be kept for years, but remained
infectious. The term virus was later used to describe such fluids, also called
“filterable agents”, which were thought to contain no particles. The virus causing
mosaic disease is now known as Tobacco mosaic virus (TMV).

 A paper commemorating Ivanovsky and Beijerinck’s work - “One Hundred Years

of Virology” - was published in Journal of Virology in 1992 to honour both
pioneers.
 The first animal viruses What is often described as the second virus ever discovered
was what is now known as Foot and mouth disease virus (FMDV) of farm and other
animals, in 1898 by the German scientists Friedrich Loeffler and Paul Frosch.

 Again, their “sterile” filtered liquid proved infectious in calves, providing the first
proof of viruses infecting animals - a fact commemorated by an article in 1998 in the
Journal of General Virology.

 Indeed, some believe that the true discoverers of viruses were these two scientists, as
they concluded the infectious agent was a tiny particle, and was not a liquid agent.

 The two went further by showing that it was possible to vaccinate cows and sheep
against the disease using filtered vesicle extract that had been heated sufficiently to
destroy its infectivity: this was possibly the first use of an inactivated virus as a
prophylactic vaccine.
 In 1898 Guiseppe Sanarelli, working in Uruguay, described the smallpox
virus relative and tumour-causing myxoma virus of rabbits as a virus but on
the basis of sterilisation by centrifugation rather than by filtration.

 This often-overlooked discovery was in fact coequal with that of FMDV as

being the first animal virus described.

 In 1892, Dmitri Ivanowski showed that this disease could be transmitted in

this way even after the Chamberland-Pasteur filter had removed all viable
bacteria from the extract. Still, it was many years before it was proven that
these “filterable” infectious agents were not simply very small bacteria, but
were a new type of tiny, disease-causing particle.
 Virions, single virus particles, are very small, about 20–250 nanometers in diameter. These
individual virus particles are the infectious form of a virus outside the host cell. Unlike
bacteria (which are about 100 times larger), we cannot see viruses with a light microscope,
with the exception of some large virions of the poxvirus family.

 It was not until the development of the electron microscope in the late 1930s that scientists
got their first good view of the structure of the tobacco mosaic virus (TMV) and other
viruses.

 The surface structure of virions can be observed by both scanning and transmission electron
microscopy, whereas the internal structures of the virus can only be observed in images
from a transmission electron microscope.

 The use of these technologies has enabled the discovery of many viruses of all types of
living organisms. They were initially grouped by shared morphology.

 Later, groups of viruses were classified by the type of nucleic acid they contained, DNA or
RNA, and whether their nucleic acid was single- or double-stranded. More recently,
molecular analysis of viral replicative cycles has further refined their classification.
 THE ORIGINS OF PUBLIC HEALTH

 The origins of public health can be traced back to ancient civilizations where rudimentary
forms of public health practices were employed to manage community health. However,
the modern concept of public health emerged in the 19th century with the rise of
industrialization and urbanization.

 Ancient Civilizations: Ancient civilizations such as those in Mesopotamia, Egypt,

Greece, and Rome implemented some forms of public health measures, including
sanitation systems, quarantine, and regulations related to food and water.

 Middle Ages: During the Middle Ages, outbreaks of infectious diseases such as the Black
Death prompted the implementation of quarantine measures and the establishment of early
forms of public health regulations in Europe.

 Enlightenment Era: The Enlightenment era brought about advancements in scientific

understanding and a greater emphasis on empirical evidence. This period saw the
beginnings of epidemiology with the work of figures like John Graunt, who analyzed
 19th Century: The 19th century marked a turning point in public health
with the emergence of scientific medicine and the recognition of the role
of sanitation and hygiene in preventing disease.

 Edwin Chadwick in Britain and Lemuel Shattuck in the United States

advocated for public health reforms, leading to improvements in
sanitation, housing, and the establishment of public health agencies.

 Germ Theory: The discovery of the germ theory of disease by

scientists like Louis Pasteur and Robert Koch in the late 19th century
revolutionized our understanding of infectious diseases and provided a
scientific basis for public health interventions.
 20th Century: The 20th century saw significant advancements in public health, including the

development of vaccines, the implementation of disease surveillance systems, and the

establishment of national and international public health agencies such as the World Health

Organization (WHO).

 Contemporary Public Health: In the 21st century, public health continues to evolve in

response to new challenges such as emerging infectious diseases, environmental health threats,

and the rise of non-communicable diseases.

 Public health efforts increasingly focus on promoting health equity, addressing social

determinants of health, and leveraging technology for disease surveillance and prevention.
 SOCIAL & PREVENTIVE MEDICINE& COMMUNITY
MEDICINE

 Preventive and social medicine is a branch of medicine dealing with providing

health services in areas of prevention, promotion and treatment of rehabilitative
diseases.

 Studies in preventive healthcare and social medicine are helpful in providing guided
care, medicine in environmental health, offering scholarly services, formulating
legal policy, consulting, and research in international work.

 While other fields of medicine deal primarily with individual health, preventive
medicine focuses on community health, with individual efforts directed toward
small groups, entire populations, and any size of group in between.
 Social medicine is an interdisciplinary field that focuses on the profound
interplay between socio-economic factors and individual health outcomes.
Rooted in the challenges of the Industrial Revolution, it seeks to:

1. Understand how specific social, economic, and environmental conditions directly

impact health, disease, and the delivery of medical care.

2. Promote conditions and interventions that address these determinants, aiming for
a healthier and more equitable society.

 Social medicine as a scientific field gradually began 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. The field of social medicine is most commonly addressed today by efforts
to understand what are known as social determinants of health
 Community Medicine

 Community medicine, also known as public health or preventive medicine, is a branch of medicine
that focuses on the health of populations rather than individual patients.

 Community Medicine is concerned with the promotion, protection, and maintenance of the health and
well-being of communities through the application of medical knowledge and skills.

 The field of community medicine encompasses a wide range of activities, including disease prevention
and control, health promotion, environmental health, epidemiology, biostatistics, health education, and
health policy.

 Community medicine practitioners work in various settings, including government health agencies,
non-governmental organizations, research institutions, and academic medical centers. They collaborate
with other healthcare professionals, community leaders, policymakers, and the public to address health
problems and develop strategies for improving health outcomes.

 Some of the key responsibilities of community medicine practitioners include conducting health
assessments and surveys, designing and implementing public health programs, monitoring and
evaluating the effectiveness of interventions, and advocating for policies that promote the health of
communities.
 HEALTH FOR ALL
 In 1977 the thirtieth World Health Assembly adopted a resolution in whcih it was decided that main
social target of Governments and of World Health Organization in the coming decades should be the
attainment by the people of the world by the year 2000 AD of a level of health that will permit them to
lead socially and economically productive life. This is popularly known as Health for All.

 Achievement of goal of Health for All aims at restructuring of health system and reorientation and
training at different categories of health workers/professionals. Fulfilment of these aims is only
possible through development of an appropriate strategy.

 During the 30th World Health Assembly the member countries of WHO defined Health For All (HFA)
as “the attainment of a level of health that will enable every individual to lead a socially and
economically productive life.” .

 The goal of HFA implies realization of WHO’s objective of attainment by all people of the highest
possible level of health which includes, physical, mental and social well-being; secondly it also implies
that as a minimum, all people in all countries should at least have such a level of health that they are
capable of being economically productive, (removal of unemployment and poverty) and participating
actively in the social life of the community in which they live i.e., have education, housing, water
 Health For All means that health care/services are to be made accessible within reach of every
individual in a given community.

 “Health For All” is a holistic concept. It calls for efforts in education, agriculture, industry,
housing and communication first, as much as in public health and medicine. It symbolizes the
determination of countries of the world to provide an acceptable level of healthful living to all
people. It is an expression of the feeling for social justice from all those who suffer inequity in
health care services.

 It is intended to draw attention to the importance of health, to a serious search for new ways of
solving the problems for health and to help mobilize all available resources for health.

 Health for all means that health is to be brought within the reach of every one in a given country
including the remotest part of a country and the poorest members of the society. By health is meant
not just the availability of health services but a sense of self help and care, a personal well-being
and a state of health that enables a person to lead a socially and economically productive life.

 “Health For All” means that health should be regarded as an objective of economic development
and not merely as one of the means of attaining it.
 The Millennium Development Goals (MDGs)
 The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond
to the world’s main development challenges. The 8 MDGs break down into 18 quantifiable targets
that are measured by 48 indicators. This article comprehensively provides all the details pertaining
to Millenium Development Goals (MDGs).
 United Nations Millenium Development Goals (MDGs) – 8 Goals
 The MDGs are drawn from the actions and targets contained in the Millennium Declaration that
was adopted by 189 nations-and signed by 147 heads of state and governments during the UN
Millennium Summit in September 2000. Full list of Goals, Targets and Indicators are provided
below.
• Goal 1: Eradicate extreme poverty and hunger
• Goal 2: Achieve universal primary education
• Goal 3: Promote gender equality and empower women
• Goal 4: Reduce child mortality
• Goal 5: Improve maternal health
• Goal 6: Combat HIV/AIDS, malaria and other diseases
• Goal 7: Ensure environmental sustainability
• Goal 8: Develop a Global Partnership for Development
  Millennium Development Goals (MDGs) – Important Features

1. It synthesizes, in a single package, many of the most important commitments made

separately at the international conferences and summits of the 1990s;

2. recognize explicitly the interdependence between growth, poverty reduction and

sustainable development;

3. acknowledge that development rests on the foundations of democratic governance, the

rule of law, respect for human rights and peace and security;

4. It is based on time-bound and measurable targets accompanied by indicators for

monitoring progress; and

5. It brings together, in the eighth Goal, the responsibilities of developing countries with
those of developed countries, founded on a global partnership endorsed at the
International Conference on Financing for Development in Monterrey, Mexico in 2002,
and again at the Johannesburg World Summit on Sustainable Development in August
2003.