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Indian Journal of Community Medicine

Public health learning and practice from hygiene to community medicine, health management and beyond issues: Challenges and options

Author(s): Kushwah SS

Vol. 32, No. 2 (2007-04 - 2007-06)


Year : 2007 | Volume : 32 | Issue : 2 | Page : 103-107

Public health learning and practice from hygiene to community medicine, health management and beyond issues: Challenges and options

Kushwah SS
Department of Community Medicine, S. S. Medical College, Rewa, Madhya Pradesh, India
Date of Submission 12-Mar-2007

Correspondence Address:
Kushwah S S
Department of Community Medicine, S. S. Medical College, Rewa, Madhya Pradesh

Source of Support: None, Conflict of Interest: None
How to cite this article:
Kushwah SS. Public health learning and practice from hygiene to community medicine, health management and beyond issues: Challenges and options. Indian J Community Med 2007;32:103-7
How to cite this URL:
Kushwah SS. Public health learning and practice from hygiene to community medicine, health management and beyond issues: Challenges and options. Indian J Community Med [serial online] 2007 [cited 2007 Nov 30];32:103-7. Available from:

We begin the journey of community health by looking back at our own past, by taking a glimpse of the present, and an insight into the future. The foundation of community medicine is set in our historical root not only through the happenings in the past but also through the ideas from primitive-to-modern that linger in our collective psyche. In other words, medical knowledge has been derived to a very great degree, from the intitutive and observational propositions and cumulative experiences gleamed from others. In course of its evolution, preceded by stages, with advances and halts, medicine has drawn richly from traditional cultures of which it is a part, and later, from biological and natural sciences, and more recently, from social and behavioral sciences.

Primitive Medicine

It has been truly said that medicine was conceived in sympathy and born out of necessity; and that the first doctor was the first man and the first woman, the first nurse. Since his knowledge was limited, the primitive man attributed disease, and in fact, all humans suffering and other calamities, to the wrath of Gods, the invasion of body by "evil spirits" and the malevolent influence of stars and planets. The concept of disease in which the ancient man believed was known as the "supernatural theory of disease." Medicine in the prehistoric times (about 5000 BC) was intermingled with superstition, religion, magic, and witchcraft. Primitive medicine are timeless still we can find so-called traditional healers" everywhere. [1]

Indian Medicine

The Indian Systems of Medicine in true sense are Ayurveda and Siddha systems. Ayurveda by definition implies the "Knowledge of life." Its origin is traced back to the Vedic times (about 5000 BC). The Indians practiced both medicine and surgery. Hygiene was given an important place in ancient Indian medicine. The laws of Manu were a code of personal hygiene. Archaeological excavations at Mohenjo-Daro and Harappa in the Indus valley uncovered cities of over 2000 years old, which revealed rather advanced knowledge of sanitation, water supply, and engineering.

Chinese Medicine

Chinese medicine claims to be the world's first organized body of medical knowledge dating back to 2700 BC. 2 Hygiene, dietics, hydrotherapy, massage, and drugs were all used by Chinese physicians. Chinese were early pioneers of immunization. They practiced variolation to prevent smallpox. Chinese brought the concept of "bare-foot doctors."

Egyptian Medicine

Egypt has one of the oldest civilizations (about 200 BC). Excavations have revealed that the Egyptians had community systems for collecting rainwater and disposal of waste. Personal cleanliness, frequent baths, and simple dress were emphasized in Egyptian civilizations. They also had some knowledge of inoculation against small pox, the value of mosquito nets, and association of plague with rats. They regarded the consequences of using alcohol as beneficial in moderation and socially troublesome in excess.

Mesopotamian (Babylonian) Medicine

Mesopotamia (now part of Iraq) civilization is around 6000 years old. Hammurabi, a great king of Babylon (1900 BC), formulated a set of laws called the code of Hammurabi, which governed the conduct of physicians and provided for good-health practices. Laws relating to medical practice, including fees payable to physicians for satisfactory services and penalties for harmful therapy are present in the Babylonian code of Hammurabi-the first codification of medical practice.

Hebrew Mosaic Law (Israel-Jewish Medicine)

Early Hebrew society extended Egyptian concepts of disease and the community promotion of health through the regulation of human conduct by the Mosaic Law or code.

The salient features of Hebrew society were as follows:

  • A weekly day of rest was a health as well as a religious measure.
  • Segregation of lepers (person suffering from leprosy).
  • Recognizing that eating pork sometimes results in illness.

The Hebrews defined conditions unacceptable for health and mobilized community forces against them.

Glory of Greece (Greek medicine)

The Greek era in history extended over many centuries, but the classic period was from 460 to 136 BC. 1 The Greeks excelled in physical aspects of personal health. Hygiea (preventive medicine) was worshipped, as the Goddess of health was a daughter of Greek leader Aeseulapius. Hippocrates the greatest physician in Greek medicine was also an epidemiologist. He distinguished between diseases that were epidemic and those that were endemic. He formulated the concept of health and disease and stressed the relation between man and his environment. He set high moral standards for the medical professionals and demanded absolute integrity of doctors in his Hippocratic Oath, which is a keystone of medical ethics.

The Roman Empire (Roman medicine)

With the destruction of Corinth in 146 BC, the health knowledge and practices of the Greeks migrated to Rome. According to the philosophy of the Romans, the state and not the individual were of primary importance. Registration of citizens and slaves, taking of a periodic census served to help in planning community health measures. Building regulation provided for ventilation and for central heating. Public sanitation was promoted through the construction of paved streets with gutters. Street cleaning and repairs were standard procedures in the interest for sanitation. Public baths were promoted as a community health measures. Protected water supply was brought to Rome from great distances via aqueducts. An outstanding figure among Roman medical teachers was Galen (130-250 AD), he observed that the disease was caused due to three factors, namely, predisposing, exciting, and environmental factors. 1

Dark Ages

The early centuries (476-1000 AD) of the medieval period of history are usually referred to as dark ages. Clergy (body of appointed ministers of Christian Church) were the only educated class; virtually, the entire emphasis of time was on the spiritual aspect of life. This is well depicted in the quotation from Saint Augustine of 5th century A.D. stating, "All diseases are to be ascribed to demons." 3 When Europe was passing through the dark ages, the Arabs stole a march over rest of the civilization. They translated the Graeco-Roman medical literature into Arabic and developed their own system of medicine known as the Unani system of medicine. They introduced a wide range of syrups, oils, poultices, plasters, pills, powders, alcoholates, and aromatic waters.

Medieval Pandemics

The later medieval period from 1000 AD to about 1453 is a period of severe pandemics and attempts to deal with the spread of disease. In 1348, bubonic plague (Black Death) followed a devastating path from Asia to Africa, the Crimea, Turkey, Greece, and Europe. From 1348 to 1350, 20% of the population of Europe died from combination of bubonic plague and pulmonary anthrax. In 1377, at Rogusa, it was ruled that travelers from plague areas should stop at designated places and remain there free of disease for two months before being allowed to enter the city. Technically, this is the first official quarantine method on record. In 1403, a quarantine of 40 days was imposed on any one suspected of having disease. Scholars of the time who turned toward the scientific approach to pestilence suffered public persecution. 3

Renaissance (Revival of Medicine/Learning)

The renaissance as the term applies to western and northern Europe encompasses the period from 1453 to 1600 AD. This period was an age of individual scientific endeavor; it ushered in a spirit of inquiry that would lead to the understanding of the cause and nature of infectious diseases. The 15th and 16th centuries produced distinguished figures as Paracelsus, Copernicus, Da Vinci, Vesalius, Galileo, and Gilbirt. By the middle of 16 th century, scholars had differentiated influenza, small pox, tuberculosis, bubonic plague, leprosy, impetigo, scabies, erysipelas, anthrax, and trachoma. Fracastaro (1478-1553) enunciated in 1546 that microorganisms cause diseases- "theory of contagion." 4 Learning advanced; however, the increasing social concentration, expanding trade, and movement of populations tended to spread diseases. Knowledge of controlling communicable diseases lagged behind the spread of the diseases, and plagues still besets humanity.

Colonial Period

As European colonized the rest of the world from 1600 to 1800, community health in North America, Australia, Africa, and South America responded to public problems in Europe. Between 1600 and 1665, Europe suffered three severe pandemics of bubonic plague. In 1658, an English investigator, Thomas Sydenham, made a differential diagnosis of scarlet fever, malaria, dysentery, and cholera. Sydenham is, generally, regarded as the first distinguished epidemiologist. In 1676, a Dutch draper, Anton Van Leeuwenhoek (1632-1723), using a microscope succeeded in seeing bacteria in a scraping from teeth. Edward Jenner (1749-1823), a British physician, scientifically demonstrated the effectiveness of smallpox vaccination. Public health was officially recognized in England in 1837 when the legislation relating to community sanitation was enacted. Particular emphasis was placed on the study of child employment conditions.

Modern Era of Health

Modern era of health is dated from 1850 to present. An organized, disciplined attack on problems of health and disease grew out of a general recognition, initially in Western societies and later in the Third World, due to the importance of a united public approach to health protection.

Miasma Phase (1850-1880)3

The term miasma means noxious air or vapor. During the miasma phase, the approach to disease control was based on the misconception that disease was caused by noxious odors. For example, diphtheria was thought to be caused by gases associated with putrefaction. People who ventured about at dusk were those who invariably contracted malaria (literally means bad air). Disease control efforts were directed entirely toward general cleanliness.

Bacteriology Phase (1880-1910)3

Bacteriology was initiated by the work of Louis Pasteur, Robert Koch, and other bacteriologists who demonstrated that a specific organism causes a specific disease. Attention was directed to such specific measures as protecting water supplies, milk, and other foods, eliminating insects and properly disposing sewage. Louis Pasteur discovered the fowl cholera bacillus and developed a method of inoculation against rabies. During this same period, Lord Joseph Lister (1827-1912) developed the practical use of phenol as an effective antiseptic.

Health Resource Phase (1910-1960) 3

It was clear that public health program had neglected the citizens as individuals and that it was necessary to build-up and maintain the highest possible level of health resources for each individual citizen. The prevention and control of communicable diseases was not enough. State health departments began expanding their programs and directing their efforts towards personal health service as well as toward community disease control.

Social Engineering Phase (1960-1975) 3

By 1960, it had become apparent that technical health advances and personal health resources were not equally available to all people. Indeed, large segments of the world and of each community were completely isolated from the developments in health. The social equity aspects of health were given a new priority in legislation and policy.

Health Promotion Phase (1974-till date)3

By the mid-1970s, a renewed interest in disease prevention and health promotion had occurred.

Developmental Milestones in India

The early triumphs of preventive medicine were in the field of bacterial vaccines and antisera. The eradication of smallpox (the last case of smallpox occurred in Somalia in 1977) is one of the greatest triumphs of preventive medicine in recent times. A new strategy has been developed for combating specific deficiencies, e.g., nutritional blindness and iodine deficiency disorders. Discovery of synthetic insecticides such as DDT, HCH, Malathion, and others add a glorious chapter to the vector control strategies. Eradication of certain other diseases (e.g., measles, tetanus, guinea worm and endemic goiter) is on the anvil. Screening of "risk factors" of disease and identification of "high-risk groups" will help in early detection of cancer, diabetes, rheumatism, and cardio-vascular diseases the so-called "diseases of civilization." Preventive medicine is currently faced with the problem of "population explosion" in developing countries. Consequently, research in human fertility and contraceptive technology has gained momentum. Besides communicable diseases, it is concerned with the environmental, social, economic, and more general aspects of prevention. In fact, as medical science advances, medical practice will become more and more preventive in nature.

Challenges for the Future

Some public health professionals in last few decades of the 20th century thought that infectious diseases could not be controlled. The indiscriminate use of antibiotics for humans and animals and in some regions neglected the basic public health principles; this resulted in resurgence of old and previously controlled infectious diseases such as tuberculosis, diphtheria, and gonorrhea. In addition, new diseases have been identified, such as hanta virus disease and bovine spongiform encephalitis, many of them resulting from human alteration of the environment and interference with the natural food chain. On the optimistic side, however, poliomyelitis is close to being eradicated and measles has been put on the public health agenda as the next target for global eradication.

Migrant workers, mothers, infants, children, adolescents, chronically-ill and elderly all need more than health services; opportunities must be provided at the community level for these people to gain control over the determinants of their health. Creating a favorable environment and living conditions for these people mean creating opportunities for self-improvement, calling for a form of social engineering. As the challenges of the future entail more complex lifestyle issues related to risk factors for injury and chronic diseases, which now accounts for the leading causes of death and disability, community health practice must be centered increasingly in schools, worksites, recreational settings, and homes. Thus, the public health professionals should be ready to deal with such challenges so that development and health can go hand in hand worldwide.

Keeping these points in mind, public health education should be included in teaching curriculum at each and every level. Various topics to be stressed at each level are as follows:

Middle School Level (grade 5-8)

  1. Knowledge of personal hygiene (cleanliness and mosquito control measures) and basic sanitation (chlorination/disinfection of water).
  2. Basic knowledge about disease spread.
  3. General safety measures for (crackers, machines, sports etc.).
  4. Spiritual health initiatives like prayers, holy meetings, yoga, and pranayam.
  5. Co-curricular activities like music, art, sports etc. should be included to reduce stress among students.

High School Level (grade 9-10)

  1. Identification of food adulterants.
  2. Nutritional knowledge and feeding practices.
  3. First aid for all kinds of injuries and life threatening situations.
  4. Proper disposal of wastes.
  5. Adolescent reproductive health education.
  6. Knowledge about various health programs and schemes by the Government of India and State Government so they can be benefited by the Government schemes.

Graduating Students

  1. All of the above points.
  2. Knowledge about contraceptives.
  3. Safety measures at different levels.
  4. Knowledge about fitness like environmental measures, dietary habits, exercises, yoga, pranayam etc.

Special learning and skill development sessions can be conducted for pregnant and lactating mothers

Preparation for pregnancy.

  1. Nutritional needs of pregnant and lactating mothers.
  2. Dos and Don'ts during pregnancy and lactation.
  3. Correct method of feeding and weaning practices for infants.
  4. Knowledge about pregnancy interval and planning the pregnancy.
  5. Knowledge about common childhood disorders and warning signs to consult a physician.

Medical Education

A review Committee should be setup by the Medical Council of India in collaboration with the Indian Association of Preventive and Social Medicine to revise the medical curriculum so that the teaching and training of community medicine is uniform throughout the country and more practical aspects should be covered in the curriculum.

If an honest effort is made to include these topics in the teaching curriculum, we will be well equipped to handle the problems of the future.


1. Park K. Man and medicine: Towards health for all. In : Textbook of Preventive and Social Medicine. 18th ed. Banarasidas Bhanot Publishers: Jabalpur; 2005. p. 1-5.
2. Smith AJ. Medicine in China: Best of the old and the new. Br Med J 1974;2:367-70. [PUBMED] [FULLTEXT]
3. Lawrence GW. Community health through the centuries. 6th ed. Times Mirror/Mosby College Publishing: St. Louis, Missouri, USA; 1990. p. 3-23.
4. Available from:


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Table 1: Milestones of miasma phase

Table 1

Table 2: Milestones of bacteriology phase

Table 2

Table 3: Milestones of health resource phase

Table 3

Table 4: Milestones of social engineering phase

Table 4

Table 5: Milestones of health promotion phase

Table 5

Table 6: Developmental milestones in India

Table 6

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