The last century witnessed the birth, growth, and maturation of community medicine
as a scientific discipline. However, changes in the health scenario at the turn of
the century posed several challenges to academic community medicine. Due to demographic
and epidemiologic transition the disease burden of chronic non-communicable diseases
and injuries is rising whereas communicable diseases, malnutrition, maternal and child
health problems are yet to be overcome. With rapid industrial growth, environmental
and occupational health problems are also likely to pose a bigger threat to population
health. Moreover, the existing health system, which is based on a biomedical model
of disease prevention and control, is not adequately geared to face these challenges.
The core function of academic community medicine is to study the health and disease
in defined communities, identify their health needs, plan and evaluate programs so
as to effectively meet their health needs. However, in the present era of globalization,
social policies at the national and international level have a profound influence
on the health of communities. This calls for new approaches to tackle determinants
of health at the local and global level. To face the emerging challenges community
physicians not only need thorough knowledge of epidemiological and bio-statistical
methods, but also need to know the relevant aspects of the social, political, economic
and environmental sciences, and the principles of administration and management. Applying
this knowledge to identify health determinants, development of public policies and
plans to address these determinants, management and evaluation of health programs
requires a variety of skills, a challenging task indeed. This calls for integration
of biomedical, ecological and sociological approaches with academic community medicine
so as to have the desired impact on population health.
The role of social policy as a primary determinant of population health was emphasized
by Rudolf Virchow, a pathologist who is considered to be the father of social medicine.(1)
McKeown also showed that infectious diseases had declined before the discovery and
use of anti-microbial agents, as a result of better living standards and improved
nutrition status which had increased people's capacity to combat infectious diseases.(2)
However, specific biomedical approaches of preventive medicine gained pre-eminence
with the advancement in the understanding of biological causes of diseases (microbes,
nutrients, chemicals). Hence, in the later part of 19th century, the practice of hygiene,
that emphasized specific preventive measures such as personal cleanliness and environmental
sanitation, became the main tool of public health for prevention and control of infectious
diseases.
In the mid 20th century, with the emergence of chronic non-communicable diseases,
integration of the biomedical and sociological approaches formed the core philosophy
of preventive and social medicine. The assimilation of family medicine with preventive
and social medicine to meet the needs of primary heath care gave birth to community
medicine in the health centers of South Africa.(3) The United Kingdom incorporated
the management of health services as one of the functions of community medicine, rechristening
community medicine as public health medicine.(4) According to Preston, this approach(5)
enhanced access to primary medical care, which was made available to the masses by
various disease prevention and control programs, and led to major declines in mortality
in developing countries during the second half of the 20th century.
Demographic transitions in Europe were triggered by the industrial revolution leading
to socio-economic development whereas in the developing world the community medicine
approach led to a decline in mortality and fertility. However, with advancing epidemiologic
transition,(6) morbidity is rising despite a fall in the mortality. In the current
situation, the traditional biomedical approach is not sufficient to stem the rise
of chronic non-communicable diseases. Public health has evolved further to emphasize
the role of social determinants, i.e., social and physical environments in shaping
the lifestyle of populations. The Ottawa charter(7) on health promotion has also emphasized
the primary role of social policy in health development. A multi-sectoral approach
is required for making substantial gains in population health.
The academic growth of community medicine can take two directions, i.e., to develop
into public health or family medicine. The focus of public health is to bring about
changes at the policy level not only for prevention of disease but also for health
promotion through organized actions at societal level, whereas family medicine has
a thrust on delivery of preventive and curative primary health care service to families
with their active participation. A family physician should be able to do more than
what an MBBS doctor (general practitioner) can do. He/she should not only be able
to deal with common medical, surgical, obstetrical, pediatric problems, and emergencies
in a Primary or Community Health Center having facilities for conducting deliveries,
admitting patients, and running round the clock emergency service but should also
be able to manage health services at these levels. Five such multitasked physicians
enabled to meet family health needs are a very cost effective substitute for five
specialists at the Community Health Center.
As the role of health in socio-economic development is becoming clearer, governments
are allocating more resources to public health. Hence, the requirement of public health
human resources will increase manifold in the near future. Indian public health standards
have specified the requirement of a public health professional in each of the community
development blocks, the Integrated Disease Surveillance Project is recruiting an epidemiologist
in every district of India, and the National Rural Health Mission has also created
the position of public health manager in most health institutions. Therefore, institutional
capacity for development of public health human resources by initiation of certificate,
diploma and degree courses of one to two year duration for pre-service and in-service
candidates from medical, nursing, laboratory, nutrition, environment, biology and
social science streams should be accorded due priority. A three-year bachelor of public
health course can be a good addition for augmenting the already depleted supervisory
cadre in the public health system. Substantial restructuring of the curricula is required
for development of competencies not only in epidemiology, health management, heath
education, and health informatics, but also in public policy, health economics, environmental
and occupational health, and health promotion. In the short-term, existing professional
resources from allied disciplines can be co-opted to build the required capacity in
community medicine and public health, two sides of the same coin.