Concepts in Public Health: A Case Study of Diarrhea Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, INDIA Dr Baridalyne N, Dr Kapil Yadav, Dr Palnivel C Prof. Chandrakant S Pandav 1

Babita, Age – 2 years

The Story……………. Baby girl aged 2 yrs Large family -5 siblings Diarrhea & Dehydration Grandmother told not to feed child during diarrhea No health facility in village Couldn’t go in the night –had to look after other children & drunken husband Mother walks to nearby hospital-10 kms away! Unfortunately the girl child dies 3

Causes of death among children under five years of age in India 4 Source- WHO- India: Mortality Country Fact Sheet 2006

Burden of Diarrheal Diseases in India 9.1% of all deaths below 6 years¹ 158,209 diarrheal deaths per year¹ 2 week prevalence- 12.2% in children < 3 years² 10.5 episodes per child per year ³ 1- National Commission on Macroeconomics and Health, National Family Health Survey 3 ( ) 3- Bhattacharya SK, NMJI, 16 (S 2):

What were the factors that led to Babita’s death? 6

No family supportMany siblings No transport Poor hygiene Diarrhea Dehydration Wrong Cultural beliefs & practices No medical facility Lack of care Illiteracy Poverty Female child< 2 yrs old 7 Malnutrition

Web of Causation 8

No family support Many siblings No transport Poor hygiene Diarrhea Dehydration Wrong Cultural beliefs And practices No medical facility Lack of care Illiteracy Low socio economic status 9 Female child Malnutrition

YES Was the death preventable?

No family support Many siblings No transport Poor hygiene Diarrhea Dehydration Poverty No medical facility Lack of care Illiteracy 11 Wrong Cultural Beliefs & practices Female child Malnutrition

No family support Many siblings Poor hygiene Diarrhea Dehydration Wrong Cultural Beliefs & practices Poverty No medical facility Lack of care Illiteracy THROUGH THE HEALTH SYSTEM 12 Female child Malnutrition

No family support Many siblings No transport Poor hygiene Diarrhea Dehydration Faulty advice Poverty No medical facility Lack of care Illiteracy OUTSIDE THE HEALTH SYSTEM 13 No medical facility Malnutrition

Concepts of disease causation Traditional Bio-medical concept –Disease caused due to the presence of causative agents –Basis in Germ theory of disease Socio- Epidemiological Concept –Causative agents alone may/may not be sufficient for disease occurrence –Social factors important in the disease causation & progression Politico- Developmental Concept –Comprehensive approach, puts health in the context of various politico- developmental situations –Effects of government policies & outfalls of development on disease occurrence, –Stems from the multi-factorial causation of disease 14

15 Traditional Bio-Medical Concept DIARRHEAL DISEASES VIBRIO CHOLERA E. COLI (Entero Pathogenic) SHIGELLA E. COLI (Entero Toxigenic) ROTA VIRUS CAMPYLOBACTERSALMONELLA CRYPTO- SPORIDIUM

Socio- Epidemiological Concept 16 & ILLITERACY

Politico- Developmental Concept 17 & ILLITERACY

Public health trains you to have a “Holistic Approach” to Health and Disease

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21 Clinical Vs Public Health Variables VariablesClinical MedicinePublic health UNIT OF STUDY Individual Population TARGET GROUP Patient – with disease Diseased/Non- Diseased VIEWPOINT OF HEALTH SYSTEM Passive process Active process TYPE OF CARE Focus on curative Comprehensive care SERVICE PROVIDERS Provided by private sector Provided by PUBLIC/private sector BENEFITS Short term benefits Obvious benefit Long term benefits Not obvious In Public Health – Good work means no epidemics

22 Axioms of Public Health Prevention is better than cure Best should not be the enemy of good Good for many rather than best for few Primary health care is NOT primitive care

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Bhore Committee “The physician of tomorrow, who will naturally be concerned with the promotion of the new era of social medicine- will be scientist and social worker, ready to cooperate in team work,, in close touch with the people he serves, a friend and leader, he directs all his efforts towards the prevention of disease, and becomes a therapist where prevention has broken down, the social physician, Protecting the people, and Guiding them to a healthier and happier life”. 24 -BHORE COMMITTEE REPORT (1946) -Health Survey & Development Committee, Government of India

Critical appraisal 25/59 YesCan’t tellNo Do you believe the results? Can the results be applied to the local population? Do the results of this study fit with other available evidence? Thank You Thank You