Modern Medicine

Dr. Alok Acharya

Assistant
Professor
Department of
Community
Medicine
• The dichotomy of medicine into two major branches
namely
– curative medicine,
– and public health/preventive medicine was evident at the close
of the 19th century.
• After 1900, medicine moved faster towards specialization,
and a rational, scientific approach to disease.
• The pattern of disease began to change.
– With the control of acute infectious diseases, the so-called
modern diseases such as cancer, diabetes, cardiovascular
disease, mental illness and accidents came into prominence
and have become the leading causes of death in industrialized
countries.
• These diseases could not be explained on the basis of
the germ theory of disease, nor treated with "magic
bullets".
• The realization began to drawn that there are other
factors or causes in the aetiology of diseases,
– namely social, economic, genetic, environmental and
psychological factors which are equally important.
• Most of these factors are linked to man's lifestyle and
behaviour.
• The germ theory of disease gave place to a newer
concept of disease - "multifactorial causation"
• Pettenkofer of Munich (1819—
1901) who first mooted the
concept of multifactorial
causation of disease but his
ideas were lost in the
bacteriological era..
• The concept of multifactorial
causation was revived by
epidemiologists who have
contributed significantly to our
present-day understanding of
multifactorial causation of
disease and "risk-factors" in
the aetiology of disease.
 Curative medicine

• Though Curative medicine is thousands of years old,

modern medicine, as we know today, is hardly 100 years
old.
• Its primary objective is the removal of disease from the
patient (rather than from the mass).
– It employs various modalities to accomplish this objective,
e.g., diagnostic techniques, treatment. Over the years, the
tools of diagnosis have become refined, sophisticated and
numerous;
– the armamentarium for treatment more specific and potent.
• In the middle of the 20th century a profound revolution
was brought in "allopathic medicine" which has been
defined as
– "treatment of disease by the use of a drug which produces
a reaction that itself neutralizes the disease" , by the
introduction of antibacterial and antibiotic agents.
– These discoveries, if they were to be recorded, would fill
volumes. Suffice it to say that curative medicine, over the
years, has accumulated a vast body of scientific knowledge,
technical skills, medicaments and machinery - highly
organized - not merely to treat disease but to preserve life
itself as far as it could be possible.
• Some specialities have emerged, based on clearly defined
skills such as surgery, radiology, and anaesthesia;
• some based on parts of the body such as ENT,
ophthalmology, cardiology, gynaecology;
• and, some based on particular age or sex groups such as
paediatrics, geriatrics and obstetrics.
• Again, within each speciality, there has been a growth of
sub-specialities, as for example, neonatology, perinatology,
paediatric cardiology, paediatric neurology and paediatric
surgery - all in paediatrics. One wonders whether such
microspecialization is needed
• Specialization has no doubt raised the standards of
medical care, but it has escalated the cost of medical care
and placed specialist medical care beyond the means of
an average citizen,
• without outside aid or charity. It has infringed upon the
basic tenets of socialism (i.e., the greatest good of the
greatest number) and paved the way to varying degrees of
social control over medicine.
• Specialization has also contributed to the decline of
general practice and the isolation of medical practitioners
at the periphery of the medical care system
 Preventive medicine
• Preventive medicine developed as a branch of medicine
distinct from public health.
• By definition, preventive medicine is applied to "healthy"
people, customarily by actions affecting large numbers or
populations. Its primary objective is prevention of disease
and promotion of health.
• The early triumphs of preventive medicine were in the field
of bacterial vaccines and antisera at the turn of the century
which led to the conquest of a wide spectrum of specific
diseases.
– Declines took place in the morbidity and mortality from
diphtheria, tetanus, typhoid fever and others.
• Later, the introduction of tissue culture of viruses
led to the development of anti-viral vaccines, e.g.,
polio vaccines (1955, 1960).
• 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.
• The search for better and newer vaccines (e.g.,
against malaria, leprosy, syphilis and other parasitic
diseases and even cancer) continues
 Discoveries in the field of nutrition

James Lind In March 1747, he was appointed surgeon of the HMS

Salisbury, a 50-gun ship in charge of patrolling the English Channel.
Vitamin C for Scurvy

• Now New strategies have been developed for combating specific deficiencies as
for example, nutritional blindness and iodine deficiency disorders. The recognition
of the role of vitamins, minerals, proteins and other nutrients, and more recently
dietary fibre emphasize the nutrition component of preventive medicine.
 Control of vectorborne diseases
• Another glorious chapter in the history of
preventive medicine is the discovery of
synthetic insecticides such as DDT, HCH,
malathion and others.
– in the control of vectorborne diseases (e.g.,
malaria, leishmaniasis, plague, rickettsial diseases)
which have been among the most important
world-wide health problems for many years.
 Chemoproph'ylaxis and mass drug
treatment
• The discovery of sulpha drugs, anti-malarials,
antibiotics, anti-tubercular and anti-leprosy drugs
have all enriched preventive medicine.
• Chemoproph'ylaxis and mass drug treatment have
become important tools of preventive medicine.
• The pattern of disease in the community began to
change with improved control of infectious diseases
through both prevention and treatment, and people
are now living for longer years, especially those in
developing countries
 Diseases elimination and Eradication
• A new concept - concept of disease
eradication - began to take shape. This
concept found ready application in the
eradication of smallpox. Eradication of certain
other diseases (e.g., measles, tetanus,
guineaworm and endemic goitre) are on the
anvil
 Screening for disease
• Another notable development in the 20th century
is the development of "screening" for the
diagnosis of disease in its presymptomatic stage.
• In the 1930s, the two most commonly used tests
were the serologic blood test for syphilis, and the
chest X-ray for tuberculosis.
• As the number of screening tests increased, the
concept of screening for individual diseases
entered the multiphasic epoch in early 1950s.
• Screening for disease among apparently healthy
people has remained an important part of
preventive medicine.
– An offshoot of the screening is screening for "risk-
factors" of disease and identification of "high-risk
groups".
– Since we do not have specific weapons against chronic
diseases, screening and regular health-checkups have
acquired an important place in the early detection of
cancer, diabetes, rheumatism and cardiovascular
disease, the so-called "diseases of civilization".
 Scope of preventive medicine
• Preventive medicine is currently faced with the problem of "population
explosion" in developing countries where population overgrowth is causing
social, economic, political and environmental problems.
• Advances in the field of treatment in no way has diminished the need for
preventive care nor its usefulness.
• Preventive measures are already being applied not only to the chronic,
degenerative and hereditary diseases but also to the special problems of old age
• As medical science advances, it will become more and more preventive medical
practice in nature.
• The emergence of 'preventive paediatrics, geriatrics and preventive cardiology
reflect newer trends in the scope of preventive medicine
• Modern preventive medicine has been defined as "the art and science of health
promotion, disease prevention, disability limitation and rehabilitation".
• It implies a more personal encounter between the individual and health
professional than public health.
 Social medicine
• In 1911, the concept of social medicine was
revived by Alfred Grotjahn (1869-1931) of
Berlin who stressed the importance of social
factors in the aetiology of disease, which he
called "social pathology".
• Others called it geographical pathology and
population pathology.
• In 1912 Rene Sand had founded the Belgian
Social Medicine Association.
• Developments in the field of social sciences (e.g., sociology,
psychology, anthropology) rediscovered that man is not
only a biological animal, but also a social being, and disease
has social causes, social consequences and social therapy.
• The ideas of social medicine spread to other countries.
• John Ryle and his group in England were influenced by
these ideas and visualized social medicine as an evolution
of medicine.
– They promoted the concept of social medicine in England.
– A Chair of social medicine was set up at Oxford in 1942 followed
by similar others in other Universities in England.
• By derivation, social medicine is the study of man
as a social being in his total environment. Its
focus is on the health of the community as a
whole.
• Professor Crew had ably stated that social
medicine stands on two pillars - medicine and
sociology.
• Others stated that the maiden sociology married
public health and became social medicine.
• McKeown has this to say: "In contemporary usage social
medicine has two meanings, one broad and ill-defined, the
other more restricted and precise.
– In the broad sense, social medicine is an expression of the
humanitarian tradition in medicine and people read into it any
interpretation consistent with their own aspirations and interests.
Thus it may be identified with care of patients, prevention of
disease, administration of medical services; indeed with almost
any subject in the extensive field of health and welfare.
– But in the more restricted sense, social medicine is concerned
with a body of knowledge embodied in epidemiology and the
study of the medical needs or medical care of society''.
• Social medicine is not a new branch of medicine but rather a new
orientation of medicine to the changing needs of man and society.
• It emphasizes the strong relationship between medicine and
social sciences.
• The pre-eminent concern of social medicine has unquestionably
been the development of epidemiological methods and their
application to the investigation of disease.
• It has entered into a productive relationship with social sciences
and statistics to be able to elucidate the role of social factors in
disease aetiology .
• These developments represent a forceful bid for the expanding
concept of medicine
 Sanitary awakening and rise of public
health
• The Industrial revolution of the 18th century sparked off
numerous problems –
– creation of slums,
– overcrowding with all its ill-effects,
– accumulation of filth in cities and towns,
– high sickness and death rates especially among women and
children,
– infectious diseases like tuberculosis, industrial and social problems
- which deteriorated the health of the people to the lowest ebb.
• The mean age at death in London was reported to be 44
years for the gentry and professionals, and 22 years for the
working class, in 1842.
• The great cholera epidemic of 1832 led Edwin
Chadwick (1800-1890), a lawyer in England to
investigate the health of the inhabitants of the
large towns with a view to improve the conditions
under which they lived .
• Chadwick's report on "The Sanitary Conditions of
the Laboring Population in Great Britain", a
landmark in the history of public health, set London
and other cities slowly on the way to improve
housing and working conditions.
• Cholera which is often called the "father of
public health" appeared time and again in
the western world during the 19th century.
• An English epidemiologist, John Snow,
studied the epidemiology of cholera in
London from 1848 to 1854 and established
the role of polluted drinking water in the
spread of cholera
 WHO definition of Public Health
• Public Health [WHO] : “The science and art of preventing
disease, prolonging life, and promoting health and
efficiency through organized community efforts for the
sanitation of the environment, the control of communicable
infections, the education of the individual in personal
hygiene, the organization of medical and nursing services
for early diagnosis and preventive treatment of disease, and
the development of social machinery to ensure for every
individual a standard of living adequate for the
maintenance of health, so organizing these benefits as to
enable every citizen to realize his birthright of health and
longevity".
 CHANGING CONCEPTS IN PUBLIC
HEALTH
• Disease control phase (1880-1920)
 aimed at the control of man’s physical
environment
 eg: Water supply ,sewage disposal, etc

• Health promotion phase (1920-1960)

 mother and child health services
 school health services
 industrial health services
 mental health & rehabilitation services
 2 movements were initiated

1. Basic health services – primary health

centres, subcentres

2. Community development programme

• Social Engineering phase [1960 – 1980]
Social and behavioral aspects of disease and health given
priority.
Social and behavioural aspects of disease and health were given a
new priority. Public health moved into the preventive and
rehabilitative aspects of chronic diseases and behavioural
problems
”risk factors” as determinants of diseases came into existence

• Health for all phase [1981 – 2000]

Members of WHO pledged “Health for all by the year 2000”
The organized application of local, state, national and
international resources permit all people to lead a socially
and economically productive life
 Functions (uses) of public health

• 1. Prevent disease and its progression, and injuries.

• 2. Promote healthy lifestyles and good health habits.
• 3. Identify, measure, monitor, and anticipate
community health needs (e.g. surveillance).
• 4. Investigate and diagnose health problems, including
microbial and chemical hazards.
• 5. Formulate, promote, and enforce essential health
policies.
• 6. Organize and ensure high-quality, cost-effective
public health and healthcare services.
• 7. Reduce health disparities and ensure access to healthcare for
all.
• 8. Promote and protect a healthy environment.
• 9. Disseminate health information and mobilize communities to
take appropriate action.
• 10. Plan and prepare for natural and man-made disasters.
• 11. Reduce the impact of interpersonal violence and aggressive
war.
• 12. Conduct research and evaluate health-promoting/ disease-
preventing strategies.
• 13. Develop new methodologies for research and evaluation.
• 14. Train and ensure a competent public health workforce.
• MEDICAL REVOLUTION
 State of the art
• Medicine has moved from the organism to
organ, and from the organ to the cell, and
from the cell to molecular properties.
• The discovery of the biological role of nucleic
acids, the uncovering of the genetic code and
its role in regulating life processes are
marvellous discoveries in recent years.
 State of the art
• Medicine has acquired new capabilities to modify and perhaps
control the capacities and activities of men by direct intervention
into and manipulation of their bodies and minds,
• viz. genetic counselling, genetic engineering, prenatal diagnosis of
sex, prenatal diagnosis of genetic diseases, in vitro fertilization, the
prospect of cloning (the asexual reproduction of unlimited number
of genetically identical individuals from a single parent), organ
transplantation, the use of artificial kidney machine, the
development of an artificial heart, the practice of psychosurgery, etc.
• The data presented show that modern medicine has entered a new
evolutionary stage with the promise of continued improvements in
medical capabilities to preserve life, if not merely to solve problems
of sickness.
 Failure of medicine
a) with increased medical costs has not come
increased benefits in terms of health
b) despite spectacular advances in medicine, the
threat posed by certain major diseases such as
malaria, schistosomiasis, leprosy, filaria,
trypanosomiasis and leishmaniasis either has not
lessened or has actually increased
c) the expectation of life has remained low and infant
and child mortality rates high in many developing
countries, despite advances in medicine
 Failure of medicine
a) historical epidemiological studies showed that
significant improvements in longevity had been
achieved through improved food supplies and
sanitation long before the advent of modern drugs and
high technology,
b) there is no equity in the distribution of health services,
resulting in limited access to health care for large
segments of the world's population, and
c) modern medicine is also attacked for its elitist
orientation even in health systems adapted to
overcome social disparities
 Social control of medicine
• When Virchow wrote in 1849 that "Medicine
is a social science and politics is medicine on a
large scale", he anticipated probably the social
(political) control of medicine.
• As the cost of medical care increased, two
kinds of medical care came into existence -
one for the rich and the other for the poor.
"Medicine is a social
science, and politics is
nothing else but medicine
on a large scale“- Rudolf
Ludwig Carl Virchow
• charitable and voluntary agencies providing
free medical care to the poor bridged the gap.
• An attitude developed that charity was
worthy of man and that the benefits of
modern medicine should be available to all
people. A solution was to be found - it was
"socialization of medicine"
• Germany led the way by instituting compulsory sickness insurance in 1883.
• Other countries followed suit - England in 1911, France in 1928 and so on.
Great Britain nationalized its health services in 1946.
• A few other countries notably the socialist nations in Europe, New Zealand
and Cuba took steps to socialize their health services. However, Russia was
the first country to socialize medicine completely and to give its citizens a
constitutional right to all health services.
• From a private ownership, medicine became a social institution, one more
link in the chain of welfare institutions .
• Socialization is a noble idea. It eliminates the competition among
physicians in search of clients.
• It ensures social equity, that is universal coverage by health services.
• Medical care becomes free for the patient, which is supported by the
State.
• The varying degrees of social control over medicine, has resulted
in a variety of health systems, each system having its own merits
and demerits.
• It is now recognized that mere socialization was not sufficient to
ensure utilization of health services. What is required is
"community participation", which, as envisaged by WHO and
UNICEF is "the process by which individuals and families assume
responsibility for their own health and welfare and for those of
the community, and develop the capacity to contribute to their
and the community's development
• It also implies community participation in the planning,
organization and management of their own health services. This is
called simply "Health by the People”
• The emergence of Family and Community
Medicine represents a counterforce to the
direction which medical science has taken
during the past 20 years or so. The field of
specialization of family and community
medicine is neither an organ system nor a
disease syndrome, but rather in both
instances, a designation of social categories
namely family and comunity
 Family medicine:

• Family medicine:
– The emergence of family medicine has been hailed as a rediscovery of the
human, social and cultural aspects of health and disease, and of the
recognition of family as a focal point of health care and the right place for
integrating preventive, promotive and curative services.
– Family medicine has been defined as "a field of specialization in medicine
which is neither disease nor organ oriented. It is family oriented medicine
or health care centred on the family as the unit - from first contact to the
ongoing care of chronic problems (from prevention to rehabilitation).
– When family medicine is applied to the care of patients and their families,
it becomes the speciality of family practice. Family practice is a horizontal
speciality, which, like paediatrics and internal medicine, shares large areas
of content with other clinical disciplines. The speciality of family practice is
specially designed to deliver "primary care"
 Community medicine
• Like family medicine, community medicine is a newcomer.
• It is the successor of what was previously known as public health,
community health, preventive and social medicine.
• The Faculty of Community Medicine of the Royal College of Physicians has
defined community medicine as "that speciality which deals with
populations and comprises those doctors who try to measure the needs of
the population, both sick and well, who plan and administer services to
meet those
• a WHO study group stated that since health problems vary from country to
country, each country should formulate its own definition of community
medicine in the light of its traditions, geography and resources.
• There is still confusion and conflict about roles, tasks and professional
identities in the service as well as the academic worlds of community
medicine
 HEALTH CARE REVOLUTION
• A very high proportion of the population in many developing countries,
and especially in rural areas does not have ready access to health services.
• The health services favoured only the privileged few and urban dwellers.
• Although there was the recognition that health is a fundamental human
right, there is a denial of this right to millions of people who are caught in
the vicious circle of poverty and illhealth.
• There are marked differences in health status between people in different
countries as well as between different groups in the same country;
• the cost of health care is rising without much improvement in their
quality.
• There has been a growing dissatisfaction with the existing health services
and a clear demand for better health care
• Health for All
• Primary health care :
– With increasing recognition of the failure of existing health services to
provide health care, alternative ideas and methods to provide health care
have been considered and tried .
– Discussing these issues at the Joint WHOUNICEF international conference
in 1978 at Alma-Ata (USSR), the governments of 134 countries and many
voluntary agencies called for a revolutionary approach to health care.
– Declaring that "The existing gross inequality in the health status of people
particularly between developed and developing countries as well as
within countries is politically, socially and economically unacceptable",
the Alma-Ata conference called for acceptance of the WHO goal of Health
for All by 2000 A.D. and proclaimed primary health care as way to
achieving "Health for All“
 – Primary health care is available to all people at the first level
of health care. It is based on principles of equity, wider
coverage, individual and community involvement and
intersectoral coordination.
– Viewed in these terms, primary health care is a radical
departure from the conventional health care systems of the
past.
– While it integrates promotive, preventive and curative
services, it is also conceived as an integral part of the
country's plan for socio-economic development
• Millennium development goals
• Sustainable development goals
 Eugenics
• Eugenics is the practice or advocacy of improving the human
species by selectively mating people with specific desirable
hereditary traits.
• It aims to reduce human suffering by “breeding out” disease,
disabilities and so-called undesirable characteristics from the
human population.
• Early supporters of eugenics believed people inherited mental
illness, criminal tendencies and even poverty, and that these
conditions could be bred out of the gene pool.
• Historically, eugenics encouraged people of so-called healthy,
superior stock to reproduce and discouraged reproduction of the
mentally challenged or anyone who fell outside the social norm.
•Thanks   