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Public health: Definition & Concept

  1. z Public Health Mona Gupta Senior Assistant Professor Vivekananda Institute of Professional Studies, affiliated to Guru Gobind Singh Indraprastha University, Delhi Definition, Concept and Development
  2. z Introduction  Great public health movements had already started in mid-nineteenth century by Edwin Chadwick in UK (report on an inquiry into the sanitary conditions of the labouring population in great Britain, 1842) and around the same time in USA in 1850 by Lemuel Shattuck (Report of the sanitary commission of Massachusetts).  These two reports initiated that brilliant movement - now known as public health, of which preventive medicine is an essential component and which has been responsible for saving billions of human lives and reducing human suffering during the last 100 years.
  3. z State of Public Health  In developing countries not even one percent of the total national budget is spent on public health; the situation, even in the developed countries is no better. For example, even in USA, just about 1% of the nation’s total health spending go towards public health.  In 1992, when the average cost of medical treatment was $3,007 for each American, the amount spent on public health was only $ 34 per person (3) !
  4.  Public health including preventive medicine, as a concept and as a science, has been a major force in furthering the cause of human health and development.  During the 20th century, many lives have been saved and diseases prevented by simple public health measures as safe water supply, sanitary excreta disposal, vaccination and insect- vector-control measures.  This gain has come from improvements in public health, broadly defined to include better housing, nutrition, sanitation, immunization and occupational safety.
  5. z Public Health  In public health, problems are named within the context of the community as a whole rather than occurring in a series of individuals. This view leads to the establishment of priorities and permits rational choices on the use of resources.  Over the years, the unique feature of public health has been acknowledged to be “Organized Community Effort” and “Systematic Social Action”.
  6. z Definition Classical definition of public health, which has stood the test of time, is the one forwarded by CEA Winslow (11) as : “The science and art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of diseases and the development of social machinery which will ensure to every individual, in the community, a standard of living adequate for maintenance of health”.
  7.  Thus public health is best identified as a social movement concerned with protecting and promoting the collective health of the community.  Thus, the province of public health is by no means limited to prevention. While mostly public health activities are funded and regulated by the Governments (National or State), the work of voluntary health agencies is also a part of public health activities since they represent an organized community effort and systematic social action.  Even a small movement by a small village to purify their drinking water source or to stop alcohol drinking is also very much a public health activity.
  8. As has been very aptly stated by Mustard “A health problem becomes a public health responsibility if, or when, it is of such character or extent as to be amenable to solution only through systematized social action”.
  9. z Preventive Medicine versus Public Health  Preventive medicine is an overall science, public health is an approach within this science. When preventive medicine starts focusing on population groups rather than individuals and utilises the approach of ‘organised community efforts” it takes the shape of public health.  The other approach of using preventive medicine is the “individualized” preventive medicine, for instance, immunising. On the other hand when the government or even a Non Governmental Organization (NGO) working with community members in a village, organises a cervical cancer screening camp, the approach becomes that of public health.
  10. z Social Medicine  It is apparent that any effort at preventing or curing the disease or making an assessment of the health problems has to take social factors into account as poverty, ignorance, overcrowding, malnutrition and so on.. This is, in essence, the concept of social medicine.  Subsequently, the concepts of social medicine merged with preventive medicine, to form the specialty of preventive & social medicine.  The considered decision was that preventive medicine should essentially combine the social aspects of health and disease in its theory, practice and teaching.
  11. z Community medicine  Community medicine, as an approach, has borrowed heavily from the concepts, methods and approaches of its two elder sisters, viz. public health and preventive medicine.  Community medicine is one pathway for representing an institution’s commitment to improving health of its immediate (or adopted) community - generally a medical college, hospital or a clinical department serve as the base.  The health task is to define the health problems, propose solutions, maintain surveillance, evaluate progress and monitor the use of resources. The approaches employed range from tools of epidemiology to the social skills, necessary for involvement with the community.  Many hospitals also established department of community medicine to bring together responsibility for the professional direction and coordination of programs in OPD and emergency, personal health, outreach satellite elements and other services.
  12. z Role of Public Health  Assessment of Health Status & Health Needs: For making assessments of health status and health needs and to reach a “community diagnosis”, with the ultimate objective of formulating health policies and planning appropriate health services.  Development of Health Policies  Assurance of the Availability and Quality of Health Services
  13. z Core Principles Underlying Public health Practice Public health specialist must develop the mental attitude to adopt these core principles in her activities:  Collective responsibility for health.  Protecting and promoting the public’s health.  A focus on whole populations and not on individuals.  An emphasis on prevention, especially primary prevention  A concern for underlying socio-economic determinants of health and disease  A multi-disciplinary basis; the readiness to work, in a team, with different and diverging disciplines concerned with human health and development.  Attitude to incorporate qualitative and quantitative methods, in the area of work.
  14. z Components of Primary Health Care There are eight essential components : (a) Education about common health problems and what can be done to prevent and control them; (b) Maternal and child health care, including family planning; (c) Promotion of proper nutrition; (d) Immunization against major infectious diseases; (e) An adequate supply of safe water; (f) Basic sanitation; (g) Prevention and control of locally endemic diseases; (h) Appropriate treatment for common diseases and injuries.
  15. z Core Activities of Public Health 1) Protecting the environment, food and water. 2) Promoting healthy behaviour through information, education and communication. 3) Assessing needs, making community diagnosis and monitoring the health status of the population/ community being served. 4) Leading to the development of sound health policy and planning. 5) Health programme management and management of other medical & health care systems (health care system includes the triad of personal medical care, public health care and other inter-sectoral initiatives related to health). 6) Preventing and investigating epidemics and maintaining surveillance on important diseases, to provide early warning.
  16. 7) Promoting the health and efficiency of the “workers” and protecting the “work-environment”. 8) Effectively responding to disasters. 9) Mobilizing community action. 10) Research to develop new insights and innovative solutions for relevant community health problems. 11) Reaching out to link the health services with the high risk, disadvantaged and hard to reach people (socioeconomically weaker sections, hilly, tribal and inaccessible areas), or those requiring special attention (women, children and old people). 12) Assuring the availability, accessibility, quality and accountability of medical care.
  17. z Aspects of Public Health ● Clear differentiation of aspects considered to be clearly the responsibility of the state or community vis-à-vis those which were clearly the responsibility of the individual. ●● Application of concepts of inter-sectoral coordination with greater appreciation of fields other than medicine like engineering, social sciences, economics, religion, etc in their contribution to provision of health and prevention of disease. ●● Provision of public health services considered to be above politics with claims of high moral ground by the proponents of public health action.
  18. z History of Public Health  The Greeks encouraged healthy living and pursued regimens of exercise and hygiene such as those prescribed by Hippocrates in his Regimen and Regimen in Acute Diseases (4th century BC). Patients visiting the temples of the god of healing, Aesculapius, were encouraged to take part in exercise, but the temples were, again, not part of a public health system.  There was some development of public health by the Minoans, a Mediterranean civilization that flourished on Crete about 3000-1050 BC. The Minoans built baths and constructed channels to supply clean water and remove waste. However, these facilities were lost when the Minoan civilization collapsed.  However, the scale of the public health system introduced by the Roman Empire from around 300 BC was without precedent in the Western world
  19. z Ancient India and Public Health Ancient Indian thoughts, philosophy developed on concepts of spirituality.  Ayurveda is the ancient science of life. It lays down the principles of management in health and disease and the code of conduct for the physician.  Charaka has described the objective of medicine as two fold; preservation of good health and combating disease.  Ayurveda emphasised the need for healthy lifestyle, including cleanliness and purity, good diet, proper behaviour and mental and physical discipline. Purity and cleanliness were to be observed in everything : jalasuddi (pure water), aharasuddi (clean food), dehasuddi (clean body), manasuddi (pure mind) and desasuddi (clean environment).
  20.  The earliest protagonists of Indian Medicine, such as Atreya, Kashyapa, Bhela, Charaka and Susruta have based their writings on the foundations of spiritual philosophy and ethics. Charaka Samhita prescribes an elaborate code of conduct.  The ruins of ancient civilizations like Mohenjadaro and Harrappa show intricate water and sullage disposal systems. It can hence be assumed that sanitation played a major part in planning of these cities.
  21. z Public Health in developed countries Revolves around three main aspects : ●● Response to an epidemic situation ●● As a regulatory or ‘police’ ●● As a means to provide improvement or better life