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Indian Journal of Community Medicine

Vol. 29, No. 4 (2004-10 - 2004-12)


What is (There) in a Name?

Nothing! As most people may pretend. Everything! As people who matter in our discipline would have us believe. Perhaps, that is why we have reinvented the tag of `Public Health' for our department. Again! Here, I wish to share my thoughts with the readers with the heartening news that a 'School of Public Health' has been established in our department. Initiation of MPH is also underway.

Let us now ponder over the issue whether this change in nomenclature is just an idiosyncrasy of our discipline; is it out of context; is it going to survive (and not give way to yet another name) or is there some definite purpose behind all this? Does this development (creation of separate schools of public health) imply that SPM/PSM/Community Medicine and Public Health will carve out their separate and distinct identities? Will Public Health be an all encompassing discipline incorporating SPM/PSM/Community Medicine under it or vice versa? Will the products from these departments fulfill different needs of the society?

At least, to me, the changing titles characterize ours as a young and dynamic discipline earnestly striving to unravel its true potentials.

But first, the issue of nomenclature........

There is a lot of confusion about the definition, scope and contents of the terms Hygiene, Public Health, Preventive Medicine, Social Medicine, and Community Medicine, Community Health and Public Health Medicine. These terms were basically borrowed from western countries (mainly UK). History of public health can be conceived in terms of three relatively distinct missions... public health as reaction to epidetnics, as a form of police, and as a means of betterment. Chronologically, these terms present a word picture of the evolution of the discipline.

Early definitions were essentially limited to sanitary measures invoked against nuisances and health hazards with which the individual was powerless to cope, and which, when present in one individual, could adversely affect others. Thus, initially insanitation and later communicability were the criteria followed in deciding if a problem fell within the purview of public health. The oldest term, HYGIENE, embodied the early knowledge about value of social and personal cleanliness. As knowledge grew, the term hygiene was felt to be too narrow and a broader term PUBLIC HEALTH was defined by Winslow i n 1920 as -

Public Health is the science and art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for -

  1. the sanitation of the environment
  2. the control of communicable infections,
  3. the education of the individual in personal hygiene,
  4. the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and
  5. the development of the social machinery to insure everyone a standard of living adequate for maintenance of health. And so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.1,2

With the great bacteriologic and immunologic discoveries of the late nineteenth and early twentieth centuries and the subsequent development of techniques for their application, the concept of prevention of disease in the individual was added. Preventive Medicine emphasized the avoidance of illness using specific measures. Prevention was initially construed narrowly in terms of protective measures like vaccination and improved nutrition that target only healthy people with the aim of preventing the onset of disease. This concept was extended to cover screening for the early diagnosis and treatment of sick persons with the aim of preventing advanced diseases and in the case of communicable disease, to preventing the spread within the community. A further extension of the definition covers the treatment of sick individuals aimed at reversing damage and restoring function. This concept led to the classification of prevention into three levels later to be differentiated into five stages.2,3

From 18th century onwards increased urbanization and industrialization, in UK, US and Europe forcefully revived an awareness of the significance of social factors in relation to disease. Health problems that developed in crowded industrial centers pointed clearly to the interrelationships of social problems and disease and to the necessity for instituting new approaches to disease prevention that involved social effort. Special attention was given to health problems of the poor and of the working class. Malnutrition was common, infant and maternal mortality high, tuberculosis and typhus rampant, housing pitiful, and other conditions of life generally unsatisfactory.

The rise of social medicine coincided with increasing realization of the links between social status and the health of individuals and communities. Statistical analyses of mortality and morbidity data during 19th century in western countries showed strong correlation between the social stratification in society and the pattern of health and disease. The objective of social medicine is to identify the social determinants of health and disease in the community and to devise mechanisms for alleviating suffering and ill health through social policies and action.4,5

Social medicine is the study of the manner in which disease may result from, cause, or accentuate social problems and how public health efforts may contribute to their solution.

The subject had achieved its first measure of academic respectability in England in 1943, when John Ryle (1889-1950) gave up the Regius Chair of Physik at Cambridge to take the new chair of social medicine that had been established at Oxford. Prior to this in 1931 Dr. Stampar was appointed Professor of Social Medicine by WHO in Zagreb. The Royal College of Physicians had also set up a Committee on Social and Preventive Medicine (SPM) in 1931. The post-war period saw a considerable expansion of social medicine as an academic discipline, with the creation of new university departments and professorial chairs, the founding of a journal and a learned society devoted to the subject. During this period social medicine was busy defining its field, establishing epidemiology as its basic science and making use of statistical methods as the `tools of the trade'.

The New Public Health phase is also described as renaissance of Public Health, or modern public health. It began in mid 1970s, with recognition of health benefits from behaviour modification and environment change, and the intrinsic connection between health and poverty and health and development. It encompasses preventive and curative services and seeks to ensure a healthy public policy. It adopts a development approach to health. The key public health perspective here is the population wide approach to the prevention, control and management of health problems. Public health capacity is the process of improving the ability of public health workforce to meet its objectives and to perform better. Opening of new schools of public health and MPH course is a step in this direction only. However, career development in Public Health with cadre restructuring are crucial to make public health profession more attractive.

In a modern interpretation of Winslow's definition, Beaglehole and Bonita 7 identified the following essential elements of modern public health.

  • collective responsibility (public = people);
  • prime role of the state in protecting and promoting the public's health;
  • partnership with the population served;
  • emphasis on prevention;
  • recognizing underlying socio-economic determinants of health and disease;
  • identifying and dealing with proximal risk factors;
  • multidisciplinary basis for action.

There are two major themes underlying the modern public health task. Firstly, as social and material inequalities within a society generate health inequalities, an important public health task is to identify through research the underlying determinants of these health inequalities. That knowledge must then be applied, in part through professional practice, to the development of health supporting social policies. Secondly, longer-term changes in the structure and conditions of the social, economic, and natural environments, at both the local and the global levels, affect the level and sustainability of good health within populations. The scope of contemporary public health practice includes the health consequences of rapid urbanization, demographic change, the globalization of economic, social, and cultural relations, and human induced global environmental changes. To be most effective, modern public health research and practice should be based on an up to date understanding of the broad determinants of the health and disease status of human population.

So, does the move to promote PUBLIC HEALTH (as a separate and distinct entity than PSM / Community Medicine) again imply emphasis on roping in non-medical experts for public health work or on bringing environmental issues again to the forefront? Yes - Public Health draws upon medical, social, science, environmental, statistical discipline and so is multidisciplinary in nature. In fact, the National Health Policy of India also emphasized the need to increase postgraduation seats in public health which should be also open to non medicos.8 Dr. Deodhar has also observed that the integration of medical and public health departments was a major blunder which resulted in gradual but substantial erosion of public health.' He therefore commends the move to start schools of public health.

Over the past few decades, the science and practice of public health has evolved and its mandate has been enlarged. Rather than being strictly confined to a limited role in disease prevention, public health has progressively become a central feature of the health sector through its involvement in policy-making, management and evaluation at every level of the health services.

Last but not the least, the opening sentences of 4th edition of Oxford Textbook of Public Health gave yet another definition -'Public Health is the process of mobilizing and engaging local, state, national and international resources to assure the conditions in which people can be healthy4 .

In a recent development the name of the journal `Public Health Medicine' (earlier known as `Community Medicine'), published from UK has been changed to `Journal of Public Health' i.e. 'Medicine' has (again) been dropped/shed. The editorial remarks indicate that these changes in names reflected a change in the name of their parent faculty.10

In fact, the inevitable and continuous extension of the boundaries of public health was clearly recognized more than 50 years ago by Mountin, who stated,

`The progressive nature of public health makes any restricted definition of the functions and responsibilities of health departments difficult. More than that - there is a real danger in attempting to narrow down a moving or growing thing. To tie public health to the concepts that answered our needs 50 years ago, or even a decade ago, can only hamstring our contribution to society in the future."11

This perceptive statement still remains valid.

STOP PRESS: Govt. To Set Up IIT. Like Institute On Health Care' (Indian Express, Oct. 28, 2004) The Health Ministry is planning to launch a National Institute of Preventive and Community Health (PCH) in Delhi next year to train specialists in PCH. The aim is to compartmentalise health care. While the doctors will not be involved in treatment of illness the govt. proposes to leave prevention of disease and community health to non-medicos. The institute will offer a two year master's degree course and a one year diploma course in PCH. The criterion (for admission) is likely to be a graduation degree in either medical or non-medical stream.12

So, friends! Now that the changes, which were brewing under the surface have started making definite and strong wave patterns be ready to ride the WAVE. The PUBLIC HEALTH is all raring to go. Fasten your seat belts.... we are shifting to top gears!


  1. Chave SPW. The Origins and Development of Public Health. In. Oxford Textbook of Public Health Vol. 1. History Determinants, Scope and Strategies. WW Holland et al (eds.) New York, Oxford University Press, 1984: 3-19.
  2. Lucas AO and Gilles HM. Short Textbook of Public Health Medicine for the Tropics. 4" edition. London, Arnold, 2003.
  3. L.eavell HR and Clark EG. Preventive Medicine for the doctor in his community - an epidemiologic approach. 3rd ed. New York. McGraw Hill, 1958.
  4. Detels R and Breslow L. Current scope and concerns in public health In. Oxford Textbook of Public Health 4th ed. Vol. l. The scope of Public Health. R. Detels et al (eds) Oxford, Oxford University Press, 2002: 1-20
  5. Hamlin C. The history and development of public health in developed countries. In. Oxford Textbook of Public Health. 4th ed. Vol. 1. The Scope of Public Health. R. Detels et al (eds). Oxford, Oxford University Press, 2002, 21-38.
  6. WHO. Networking of Public Health Institutions - Report of Intercountry Meeting, New Delhi, I1-14 Feb. 2003. Geneva, World Health Organization. 2003.
  7. Beaglehole R and Bonita R. Public Health At The Crossroad. Cambridge, Cambridge University Press, 1997
  8. Kishore J. National Health Programmes of India. National Policies and L.egislations Related to Health. 4th edition, New Delhi, Century Publication, 2002.
  9. Deodhar NS. Public Health System in India with Special Reference to Schools of Public Health. Document prepared for (and discussed during) National Consultation on Institutes of Public Health In India - From Concept to Reality. Sept. 16-17, 2004, N. Delhi.
  10. Editorial Remark. Journal of Public Health. 2004; 26: 2
  11. Hanlon JJ and Pickett GE. Public Health Administration and Practice. 8''' edition. Toronto, Times Mirror/Mosby College Publishing, 1984
  12. The Indian Express, Oct. 28, 2004, vol. 28, no. 70, p. 2
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