Man and medicine: Concept of health and disease

Q. Define community medicine.

Ans. - 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 needs, and those
who are engaged in research and teaching in the field".

Community medicine is the successor of what was previously known as

public health, community health, preventive and social medicine. All
these share common ground, i.e., prevention of disease and promotion
of health.

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.

It will be seen that a common thread runs through all the above
definitions. Diagnosis of the state of health of a community is an
important foundation of community medicine. As used in the present
context, community medicine is a practice which focuses on the health
needs of the community as a whole.

The combination of community medicine with "primary health care"

extends the functioning of both elements to a health care system
which aims to change the state of health of the community by
intervention both at the individual and group level.
Q. Changing concept in public health.
Ans. - The term public health came into general use around 1840. It arose
from the need to protect the public from the spread of communicable
diseases. The WHO expert committee on Public health administration
has defined it as

“The science and art of preventing disease, prolonging life, and

promoting health and efficiency through organised community effort’s
for the sanitation of environment, the control of communicable
infections, the education of the individual in personal hygiene, the
organisation of medical and nursing services for early diagnosis and
preventive treatment of disease, and the development of social
machinery to ensure for every individual standard of living adequate
for the maintenance of health, so organising these benefits as to
enable every citizen realise his birthright of health and longevity.”

In developing countries public health has not made such headway in

terms of sanitary reforms and control of communicable diseases as it
has made tremendous strides in industrialised western countries. As a
result public health in developed countries has moved from sanitation
and control of communicable diseases to preventive, therapeutic and
rehabilitative aspects of chronic diseases and behavioural disorders.

An EURO symposium in 1966 suggested that the definition of public

health should be expanded to include the organization of medical care
services. Thus modern public health also includes organization of
medical care, as a means of protecting and improving the health of
people.

Public health, in its present form, is a combination of scientific

disciplines and skills and strategies that are directed to the
maintenance and improvement of the health of the people.
 With the adoption of the goal of "Health for All", a new public health
was evident worldwide, which may be defined as:

"the organized application of local, state, national and

international resources to achieve "Health for All", i.e., attainment by
all people of the world by the year 2000 of a leuel of health that will
permit them to lead a socially and economically productiue life".

Q. The millennium development goals.

Ans. - In September 2000, representatives from 189 countries met at the
Millennium Summit in New York to adopt the United Nations Millennium
Declaration. The leaders made specific commitments in seven areas :

1) peace, security and disarmament

2) development and poverty eradication
3) protecting our common environment
4) human rights, democracy and good governance
5) protecting the vulnerable
6) meeting the special needs of Africa and
7) strengthening the United Nations.

The Road Map established goals and targets to be reached by the

year 2015 in each of seven areas. The goals in the area of
development and poverty eradication are now widely referred to as
"Millennium Development Goals".

The Millennium Development Goals, place health at the heart of

development. Thus three of the eight goals are directly health related
and all of other goals have important indirect effects on health.

Three of the 8 goals, 8 of the 18 targets required to achieve these

goals, and 18 of the 48 indicators of progress, are health related.
Q. PQLI.
Ans. - Various attempts have been made to reach one composite index from
a number of health indicators to define and measure quality of life.
The “Physical quality of life index" is one such index.

It consolidates three indicators, viz.

1) infant mortality,
2) life expectancy at age one, and
3) literacy.
These three components measure the results rather than inputs.

For each component, the performance of individual countries is placed

on a scale of 0 to 100, where 0 represents an absolutely defined
"worst" performance, and 100 represents an absolutely defined "best"
performance. The composite index is calculated by averaging the three
indicators, giving equal weight to each of them. The resulting PQLI
thus also is scaled 0 to 100.

PQLI does not measure economic growth; it measures the results of

social, economic and political policies. It is intended to complement, not
replace GNP (Gross national product).
Q. Human development index (HDI).
Ans. - Human development index (HDI) is defined as "a composite index
focusing on three basic dimensions of human development:

1) to lead a long and healthy life measured by life expectancy at birth

2) the ability to acquire knowledge, measured by mean years of
schooling and expected years of schooling and
3) the ability to achieve a decent standard of living, measured by gross
national income per capita in PPP (Purchasing power parity) US $.

The HDI is a more comprehensive measure than per capita income.

The HDI values range between 0 to 1. The HDI value for a country
shows the distance that it has already travelled towards maximum
possible value to 1, and also allows comparisons with other countries.

STEPS TO ESTIMATE THE HUMAN DEVELOPMENT INDEX

Step 1. Creating the dimension indices Minimum and maximum values

(goalposts) are set in order to transform the indicators into indices
between 0 and 1.
Having defined the minimum and maximum values, the subindices are
calculated as follows:
 q

Step 2. Aggregating the subindices to produce the Human Development

Index.
The HDI is the geometric mean of the three dimension indices:

Q. Differentiate between PQLI and HDI.

Ans. -

W 130
MM
Q. Health development.
Ans. - Health development is defined as:

"the process of continuous progressive improvement of the

health status of a population".

Its product is rising level of human well-being, marked not only by

reduction in the burden of disease, but also by the attainment of
positive physical and mental health related to satisfactory economic
functioning and social integration.

The concept of health development as distinct from the provision of

medical care is a product of recent policy thinking. It is based on the
fundamental principle that governments have a responsibility for the
health of their people and at the same time people should have the
right as well as the duty, individually and collectively to participate in
the development of their own health.

Health development contributes to and results from social and

economic development. Therefore, health development has been given
increasing emphasis in the policies and programmes of the United
Nations system.

One example is that of World Bank which is providing funds for the
health component of economic development programmes.
Q. Classify indicators of health and discuss in brief.
Q. Enumerate the indicators of health. Discuss two most important mortality
indicators.
Ans. - Health indicators are defined as “variables which help to measure
changes.” They are used particularly when these changes cannot be
measured directly, as for example health or nutritional status. If
measured sequentially over time, they can indicate direction and speed
of change and serve to compare different areas or groups of people at
the same moment in time. Health index is generally considered to be
an amalgamation of health indicators.

Health indicators may be classified as:

1. Mortality indicators
2. Morbidity indicators
3. Disability rates
4. Nutritional status indicators
5. Health care delivery indicators
6. Utilization rates
7. Indicators of social and mental health
8. Environmental indicators
9. Socio-economic indicators
10. Health policy indicators
11. Indicators of quality of life and
12. Other indicators.

1. Mortality indicators
1. Expectation of life :
Life expectancy at birth is "the average number of years that will be
lived by those born alive into a population if the current age-specific
mortality rates persist".

Life expectancy at birth is highly influenced by the infant mortality

rate where that is high. Life expectancy at the age of 1 excludes the
influence of infant mortality, and life expectancy at the age of 5
excludes the influence of child mortality.

It is estimated for both sexes separately. An increase in the

expectation of life is regarded, inferentially, as an improvement in
health status.

Life expectancy is a good indicator of socio-economic development in

general. As an indicator of long-term survival, it can be considered as
a “positive health indicator.”

It has been adopted as a global health indicator.

2. Infant mortality rate :

Infant mortality rate is the ratio of deaths under 1 year of age in a
given year to the total number of live births in the same year; usually
expressed as a rate per 1000 live births.

It is one of the most universally accepted indicators of health status

not only of infants, but also of whole population and of the socio-
economic conditions under which they live.

In addition, the infant mortality rate is a sensitive indicator of the

availability, utilization and effectiveness of health care, particularly
perinatal care.
2. Morbidity indicators

Mortality indicators do not reveal the burden of ill-health in a

community, as for example mental illness and rheumatoid arthritis.
Therefore, morbidity indicators are used to supplement mortality data
to describe the health status of a population.

3. Disability indicators

Since death rates have not changed markedly in recent years,

disability rates related to illness and injury have come into use to
supplement mortality and morbidity indicators.

The disability rates are based on the premise or notion that health
implies a full range of daily activities.
4. Nutritional status indicator

Nutritional status is a positive health indicator. Three nutritional status

indicators are considered important as indicators of health status. They
are :
a. anthropometric measurements of preschool children, e.g., weight
and height, mid-arm circumference
b. heights of children at school entry and
c. prevalence of low birth weight (less than 2.5 kg).

5. Healthcare delivery indicators

These indicators reflect the equity of distribution of health resources

in different parts of the country, and of the provision of health care.
The frequently used indicators of health care delivery are:
a. Doctor-population ratio
b. Doctor-nurse ratio
c. Population-bed ratio
d. Population per health/subcentre, and
e. Population per trained birth attendant.

6. Utilisation rates

Utilization of services - or actual coverage - is expressed as the

proportion of people in need of a service who actually receive it in a
given period, usually a year.

A few examples of utilization rates are:

a. proporltion of infants who are "fully immunized" against the 9 EPI
diseases.
b. proporltion of pregnant women who receive antenatal care, or have
their deliveries supervised by a trained birth attendant.
7. Indicators of social and mental health

These include suicide, homicide, other acts of violence and other

crime; road traffic accidents, juvenile delinquency; alcohol and drug
abuse; smoking; consumption of tranquillizers; obesity, etc. These social
indicators provide a guide to social action for improving the health of
the people.

8. Environmental indicators

Environmental indicators reflect the quality of physical and biological

environment in which diseases occur and in which the people live. They
include indicators relating to pollution of air and water, radiation, solid
wastes, noise, exposure to toxic substances in food or drink. Among
these, the most useful indicators are those measuring the proportion
of population having access to safe water and sanitation facilities.

9. Socio-economic indicators

These indicators are of great importance in the interpretation of the

indicators of health care. These include:
a. rate of population increase
b. per capita GNP
c. level of unemployment
d. dependency ratio
e. literacy rates, especially female literacy rates
f. family size
g. housing: the number of persons per room, and
h. per capita "calorie" availability.
10. Health policy indicators

The single most important indicator of political commitment is

"allocation of adequate resources". The relevant indicators are:
(i) proportion of GNP spent on health services
(ii) proportion of GNP spent on health-related activities (including
water supply and sanitation, housing and nutrition, community
development), and
(iii) proportion of total health resources devoted to primary health
care.

11. Indicators of quality of life

It consolidates three indicators, viz.

a. infant mortality,
b. life expectancy at age one, and
c. literacy.

12. Social indicators

Social indicators, as defined by the United Nations Statistical Office,

have been divided into 12 categories:- population; family formation,
families and households; learning and educational services; earning
activities; distribution of income, consumption, and accumulation; social
security and welfare services; health services and nutrition; housing
and its environment; public order and safety; time use; leisure and
culture; social stratification and mobility.

13. Basic needs indicators

These include calorie consumption; access to water; life expectancy;

deaths due to disease; illiteracy, doctors and nurses per population;
rooms per person; GNP per capita.
Q. DALY (Disability adjusted life years).
Ans. - DALY is a measure of overall disease burden, expressed as a number of
years lost due to ill-health, disability or early death. It captures the
population impact of important fatal and non-fatal disabling conditions
through a single measure.

The major measure used is disability-adjusted life years (DALYs) which

combines:

1) years of lost life (YLL) - calculated from the number of deaths at

each age multiplied by the expected remaining years of life according
to a global standard life expectancy
2) years lost to disability (YLD) - where the number of incident cases
due to injury and illness is multiplied by the average duration of the
disease and a weighting factor reflecting the severity of the disease
on a scale from 0 (perfect health) to 1 (dead).

It is calculated by formula : DALY = YLL + YLD

The DALY relies on an acceptance that the most appropriate measure

of the effects of the chronic illness is time. One DALY, therefore, is
equal to one year of healthy life lost.

Japanese life expectancy statistics are used as a standard for

measuring premature death, as Japanese have the longest life
expectancy.

DALYs can measure ‘both mortality and disability together’.

Q. Epidemiological triad.
Ans. - Epidemiological triad is defined as interaction
between agent, host and environment.

This triad is based on the communicable

disease model and is useful in showing the
interaction and interdependence of agent,
host and environment as used in the
investigation of diseases and epidemics.

The agent is the cause of disease; the host is an organism, usually a

human or an animal, that harbours the disease and the environment is
those surroundings and conditions external to the human or animal
that cause or allow disease transmission.

Agents of infectious diseases include bacteria, viruses, parasites, fungi,

and molds. With regard to non-infectious disease, disability, injury, or
death, agents can include chemicals from dietary foods, tobacco smoke,
solvents, radiation or heat, nutritional deficiencies, or other substances,
such as poison. One or several agents may contribute to an illness.

A host offers subsistence and lodging for a pathogen and may or may
not develop the disease. The level of immunity, genetic makeup, level
of exposure, state of health, and overall fitness of the host can
determine the effect a disease organism will have on it.

Environmental factors can include the biological aspects as well as

social, cultural, and physical aspects of the environment. The
surroundings in which a pathogen lives and the effect the
surroundings have on it are a part of the environment. Environment
can be within a host or external to it in the community.
Q. Multifactorial causation of disease.
Ans. - The so-called "modern" diseases of civilization, e.g., lung cancer,
coronary heart disease, chronic bronchitis, mental illness, etc. could
not be explained on the basis of the germ theory of disease nor
could they be prevented by the traditional methods of isolation,
immunization or improvements in sanitation.

The realization began to dawn that the "single cause idea" was an
oversimplification and that there are other factors in the aetiology of
diseases - social, economic, cultural, genetic and psychological which
are equally important.

As tuberculosis is not merely due to tubercle bacilli; factors such as

poverty, overcrowding and malnutrition contribute to its occurrence.

The doctrine of one-to-one relationship between cause and disease

has been shown to be untenable, even for microbial diseases, e.g.,
tuberculosis, leprosy.

Diseases such as coronary heart disease and cancer are due to

multiple factors. For example, excess of fat intake, smoking, lack of
physical exercise and obesity are all involved in the pathogenesis of
coronary heart disease. Most of these factors are linked to lifestyle
and human behaviour.
This theory is known as multifactorial causation of disease.

The purpose of knowing the multiple factors

of disease is to quantify and arrange them in
priority sequence (prioritization) for
modification or amelioration to prevent or
control disease. The multifactorial concept
offers multiple approaches for the
prevention/control of disease.
Q. What do you understand by natural history of diseases? Discuss briefly
how its knowledge helps us to prevent and control a disease in community.
Ans. - The term natural history of disease signifies the way in which a
disease evolves over time from the earliest stage of its
prepathogenesis phase to its termination as recovery, disability or
death, in the absence of treatment or prevention.

Each disease has its own unique natural history, which is not
necessarily the same in all individuals, so much so, any general
formulation of the natural history of disease is necessarily arbitrary.

The natural history of disease is best established by cohort studies. As

these studies are costly and laborious, what is known about the
natural history of any disease is constructed largely from observations
of affected persons followed over time.

The natural history of disease consists of two phases:

1) Prepathogenesis Phase of Disease

• Is period before onset of disease in man (man at risk)
• Epidemiologicaltriad: Interaction between agent, host and
environment
• Primary level of prevention is possible

2) Pathogenesis Phase of Disease

• Begins with: ‘Entry of organism’ in susceptible host
• Multiplication of organism, disease initiation and progression
• Final outcome may be recovery, disability or death
• Host may become a clinical case, subclinical case or carrier
• Secondary and tertiary levels of prevention are possible
• Screening of disease may improve prognosis and increase survival
 Prepathogenesis Phase l Pathogenesis Phase

Prevention and control

The principles of etiology and natural history of disease are essential
to recognizing opportunities for prevention across the illness spectrum.

They have a bearing on how illness is experienced, how differently it

can be perceived at the time of first contact with the health system,
and how it may appear at later stages.

Opportunities for prevention arise at every stage in the process, and

three main levels are described: primary, secondary, and tertiary.

Prevention strategies include health promotion focused on

determinants, clinical prevention to reduce modifiable risk factors, case
finding, screening, and addressing functional outcomes relevant to
quality of life; the importance of preventing errors is also recognized.
Q. Discuss natural history of disease. Describe risk factor, risk groups and
iceberg of disease.
Ans. - RISK FACTORS

For many diseases, the disease "agent" is still unidentified, e.g.

coronary heart disease, cancer, peptic ulcer, mental illness, etc.
Where the disease agent is not firmly established, the aetiology is
generally discussed in terms of "risk factors".

Risk factors may be defined as:

a. an attribute or exposure that is significantly associated with the
development of a disease
b. a determinant that can be modified by intervention, thereby
reducing the possibility of occurrence of disease or other specified
outcomes

Risk factors are often suggestive, but absolute proof of cause and
effect between a risk factor and disease is usually lacking. That is,
the presence of a risk factor does not imply that the disease will
occur, and in its absence, the disease will not occur.

The important thing about risk factors is that they are observable or
identifiable prior to the event they predict.

It is also recognized that combination of risk factors in the same

individual may be purely additive or synergistic (multiplicative).
# For example, smoking and occupational exposure (shoe, leather,
rubber, dye and chemical industries) were found to have an additive
effect as risk factors for bladder cancer.
# On the other hand, smoking was found to be synergistic with other
risk factors such as hypertension and high blood cholesterol. That is,
the effects are more than additive.
# Risk factors may be truly causative (e.g., smoking for lung cancer);
# they may be merely contributory to the undesired outcome (e.g.,
lack of physical exercise is a risk factor for coronary heart disease),
# or they may be predictive only in a statistical sense (e.g., illiteracy
for perinatal mortality).

Some risk factors can be modified; others cannot be modified.

# The modifiable factors include smoking, hypertension, elevated serum
cholesterol, physical activity, obesity, etc. They are amenable to
intervention and are useful in the care of the individual.
# The unmodifiable or immutable risk factors such as age, sex, race,
family history and genetic factors are not subject to change. They act
more as signals in alerting health professionals and other personnel to
the possible outcome.

Risk factors may characterize the individual, the family, the group,
the community or the environment. For example, some of the individual
risk factors include age, sex, smoking, hypertension, etc. But there are
also collective community risks -for example, from the presence of
malaria, from air pollution, from substandard housing, or a poor water
supply or poor health care services.

The detection of risk factors should be considered a prelude to

prevention or intervention.

RISK GROUPS

Another approach developed and promoted by WHO is to identify

precisely the "risk groups" or "target groups" (e.g., at-risk mothers,
at-risk infants, at-risk families, chronically ill, handicapped, elderly) in
the population by certain defined criteria and direct appropriate
action to them first. This is known as the "risk approach".
 It has been summed up as "something for all, but more for those in
need-in proportion to the need". In essence, the risk approach is a
managerial device for increasing the efficiency of health care services
within the limits of existing resources.

Modern epidemiology is concerned with the identification of risk

factors and high-risk groups in the population. Since resources are
scarce, identification of those at risk is imperative. It helps to define
priorities and points to those most in need of attention.

Q. Iceberg of disease (Iceberg phenomenon).

Ans. - According to this concept, disease in a
community may be compared with an iceberg.

# The floating tip of the iceberg represents

what the physician sees in the community, i.e.,
clinical cases.
# The vast submerged portion of the iceberg represents the hidden
mass of disease, i.e., latent, inapparent, presymptomatic and
undiagnosed cases and carriers in the community.
# The "waterline" represents the demarcation between apparent and
inapparent disease.

In some diseases (e.g., hypertension, diabetes, anaemia, malnutrition,

mental illness) the unknown morbidity (i.e., the submerged portion of
the iceberg) far exceeds the known morbidity.

The hidden part of the iceberg thus constitutes an important,

undiagnosed reservoir of infection or disease in the community, and its
detection and control is a challenge to modern techniques in
preventive medicine.
Q. Disease eradication. Differentiate it from disease elimination.
Ans. - Eradication literally means to "tear out by roots". Eradication of disease
implies termination of all transmission of infection by extermination of
the infectious agent.

Eradication is an absolute process, and not a relative goal. It is "all or

none phenomenon". The word eradication is reserved to cessation of
infection and disease from the whole world.

During recent years, three diseases have been seriously advanced as

candidates for global eradication within the foreseeable future: polio,
measles and dracunculiasis. The feasibility of eradicating polio appears
to be greater than that of others and the goal is in sight as
Afghanistan and Pakistan are the only two countries endemic for
poliomyelitis at present.

Elimination
It is an intermediate goal between control and eradication. The term
"elimination" is used to describe interruption of transmission of disease,
but the organism still persists. As for example, elimination of measles,
polio and diphtheria from large geographic regions or areas.
Q. Differentiate Control and Eradication.
Ans. - The term "disease control" describes (ongoing) operations aimed at
reducing:
i. the incidence of disease
ii. the duration of disease, and consequently the risk of transmission
iii. the effects of infection, including both the physical, and
psychosocial complications; and
iv. the financial burden to the community.

In disease control, the disease "agent" is permitted to persist in the

community at a level where it ceases to be a public health problem
according to the tolerance of the local population. A state of
equilibrium becomes established between the disease agent, host and
environment components of the disease process.

An excellent embodiment of this concept is malaria control, which is

distinct from malaria eradication.

Control activities may focus on primary prevention or secondary

prevention, most control programmes combine the two. The concept of
tertiary prevention is comparatively less relevant to control efforts.

Q. Differentiate monitoring and surveillance.

Ans. -
i) Monitoring
Monitoring is "the performance and analysis of routine measurements
aimed at detecting changes in the environment or health status of
population". e.g., monitoring of air pollution, water quality, growth and
nutritional status, etc.

It also refers to on-going measurement of performance of a health

service or a health professional or of the extent to which patients
comply with or adhere to advice from health professionals.

In management, monitoring refers to "the continuous oversight of

activities to ensure that they are proceeding according to plan. It
keeps track of achievements, staff movements and utilization, supplies
and equipment, and the money spent in relation to the resources
available so that if anything goes wrong, immediate corrective
measures can be taken".

ii) Surveillance
Surveillance means to watch over with great attention, authority and
often with suspicion. Surveillance is also defined as "the continuous
scrutiny of the factors that determine the occurrence and distribution
of disease and other conditions of ill-health".

The main objectives of surveillance are:

(a) to provide information about new and changing trends in the health
status of a population, e.g., morbidity, mortality, nutritional status or
other indicators and environmental hazards, health practices and other
factors that may affect health
(b) to provide feed-back which may be expected to modify the policy
and the system itself and lead to redefinition of objectives, and
(c) provide timely warning of public health disasters so that
interventions can be mobilized.
Q. Differentiate monitoring and evaluation.
Ans. - Evaluation
Evaluation is the process by which results are compared with the
intended objectives, or more simply the assessment of how well a
programme is performing.

Evaluation should always be considered during the planning and

implementation stages of a programme or activity. Evaluation may be
crucial in identifying the health benefits derived (impact on morbidity,
mortality, sequelae, patient satisfaction). Evaluation can be useful in
identifying performance difficulties.

Evaluation studies may also be carried out to generate information for

other purposes, e.g., to attract attention to a problem, extension of
control activities, training and patient management, etc.

Q. Discuss levels of prevention. Differentiate primordial and primary

prevention.
Ans. - The goals of medicine are to promote health, to preserve health, to
restore health when it is impaired, and to minimize suffering and
distress. These goals are embodied in the word "prevention"
Primordial Level of Prevention

• It is the prevention of the emergence or development of risk factors

in countries or population groups in which they have not yet appeared

• Modes of Intervention:
– Individual Education
– Mass Education

• Is primary prevention in purest sense

• Primordial Level is Best level of prevention for Non-communicable

diseases

Primary Level of Prevention

• It is the action taken prior to onset of disease, which removes the

possibility that a disease will ever occur

• Modes of Intervention:
a. Health Promotion: Is targeted at strengthening the host through a
variety of approaches/interventions
Example: Health Education, Environmental modifications, Nutritional
interventions, Lifestyle and behavioural changes
b. Specific Protection: Is targeting the prevention of disease through a
specific intervention
Example: Contraception, Vaccines

• Primary level of prevention is applied when ‘risk factors are present

but disease has not yet taken place’
• It signifies ‘intervention in the Pre-pathogenesis Phase of a disease/
health problem.
Q. Differentiate secondary and tertiary prevention.
Ans. - Secondary Level of Prevention

• It halts the progress of disease at it’s incipient stage and prevents

complications

• Modes of Intervention:
- Early Diagnosis: Detection of disturbances while biochemical,
functional and morphological changes are still reversible or prior to
occurrence of manifest signs and symptoms. Examples: Sputum smear
exam for AFB, P/S for MP
- Treatment: Shortens period of communicability, reduces mortality and
prevents occurrence of further cases (secondary cases) or any long
term disability. Example: DOTS, MDT

• Secondary level of prevention is applied when disease has possibly

set in: It attempts to arrest the disease process, seek unrecognized
disease and treat it before irreversibility and reverse communicability
of infectious diseases

• National Health Programmes by Govt. of India mostly operate at

Secondary level of prevention

• Secondary prevention is an imperfect tool in control of transmission

of disease: It is more expensive and less effective than primary
prevention

• It is an important level of prevention for diseases like Tuberculosis,

Leprosy and STDs
Tertiary Level of Prevention

• Is applied when disease has advanced beyond early stages: It aims

to reduce or limit impairments and disabilities, minimize suffering
caused by existing departures from good health

• Modes of Intervention:
- Disability Limitation: It ‘prevents the transition of disease from
impairment to handicap’. Example: Physiotherapy in Poliomyelitis
- Rehabilitation: Training and retraining of an individual to the highest
possible level of functional ability; it can be medical, vocational, social
or psychological. Example: Crutches in Poliomyelitis

• Tertiary level of prevention signifies ‘intervention in late

pathogenesis phase’
Q. Differentiate impairment, disability and handicap.
Ans. - (i) Impairment : An impairment is defined as "any loss or abnormality
of psychological, physiological or anatomical structure or function",
e.g., loss of foot, defective vision or mental retardation. An impairment
may be visible or invisible, temporary or permanent, progressive or
regressive. Further, one impairment may lead to the development of
"secondary" impairments as in the case of leprosy where damage to
nerves (primary impairment) may lead to plantar ulcers (secondary
impairment).

(ii) Disability : Because of an impairment, the affected person may be

unable to carry out certain activities considered normal for his age,
sex, etc. This inability to carry out certain activities is termed
"disability". A disability has been defined as "any restriction or lack of
ability to perform an activity in the manner or within the range
considered normal for a human being".

(iii) Handicap : As a result of disability, the person experiences certain

disadvantages in life and is not able to discharge the obligations
required of him and play the role expected of him in the society. This
is termed "handicap", and is defined as "a disadvantage for a given
individual, resulting from an impairment or a disability, that limits or
prevents the fulfilment of a role that is normal (depending on age,
sex, and social and cultural factors) for that individual".

Taking accidents as an example, the above terms can be explained

further as follows:
Q. Rehabilitation.
Ans. - Rehabilitation is defined as "the combined and coordinated use of
medical, social, educational and vocational measures for training and
retraining the individual to the highest possible level of functional
ability".

It includes all measures aimed at reducing the impact of disabling and

handicapping conditions and at enabling the disabled and handicapped
to achieve social integration.

Social integration has been defined as the active participation of

disabled and handicapped people in the mainstream of community life.

It involves Rehabilitation medicine or Physical medicine or Physiatry as

a medical speciality. It aims to enhance and restore functional ability
and quality of life to those with physical impairments or disabilities.

The following areas of concern in rehabilitation have been identified:

(a) Medical rehabilitation -restoration of function.
(b) Vocational rehabilitation -restoration of the capacity to earn a
livelihood.
(c) Social rehabilitation -restoration of family and social relationships.
(d) Psychological rehabilitation -restoration of personal dignity and
confidence.

Examples of rehabilitation are: establishing schools for the blind,

provision of aids for the crippled, reconstructive surgery in leprosy,
muscle re-education and graded exercises in neurological disorders,
change of profession for a more suitable one and modification of life in
general in the case of tuberculosis, cardiac patients and others.