Community Medicine medical care directed towards service of the entire population of the community, with emphasis on preventive medicine. Illnesses have been seen in the past as individual issues affecting a victim. In fact, the system of medicine traditionally developed in a manner that diseases were treated as matters of individual concern. Occasionally, follies and prejudices propelled by religious dogmatism made this individualistic notion of disease even more pronounced. For instance, infirmity and illness were considered penalties for vice.
With advances in scientific knowledge and better understanding of the causes of disease, knowledge about germs, relationship of nutrition and illness, and progress in the science of epidemiology etc, new dimensions in medicine have been opened. Subjects like social medicine and community medicine have been introduced to describe certain aspects of science to focus the community at the centre of interventions rather health of individuals. Certainly, certain types of problems can be better addressed through the community than the individual. For instance, a nation-wide nutritional education campaign with respect to food habits that would reduce vitamin A deficiency and prevent night blindness would eventually benefit individuals, but the community approach would yield faster results in the long run with less cost.
Today, the world is a 'global health village' with shared health threats. Diseases are no more respectful of national boundaries but due to increased human mobility can rapidly spread to vast areas across many countries, and often continents lying across vast stretches of ocean. Human health can no more be regarded as isolated regional problems that can be tackled by an isolated approach, but requires joint action and joint responsibility towards addressing shared problems. The Alma-Ata declaration endorsed 'Health for all by the year 2000' but the honest intention is not achieved.
Community medicine addresses issues such as cheaper methods of treatment, less costly inputs to achieve health, cheap and effective methods to train and use community workers in health care, efficient deployment of resources by identifying high-risk targets, community motivation, health awareness creation etc.
Bangladesh has a huge population but relatively easily accessible communities. This is partly due to the fact that population density is high which offers certain advantages in community medicine because access to communities is less costly logistically.
The lead work in community medicine in Bangladesh was triggered by the dreadful disease cholera, which for many years killed tens of thousands in explosive epidemics that came with remarkable regularity. The Vietnam War in the 1950s provided an incentive to the South East Asia Treaty Organisation (SEATO), which was created in 1956 to counter the spread of communism in Southeast Asia, and to support research on cholera with the aim of protecting American soldiers fighting in the area.
The Pakistan SEATO Cholera Research Laboratory (PSCRL) was established in Dhaka in 1960. This institution in its early years of operation carried out clinical studies on cholera patients and made valuable contributions to the discovery of the oral rehydration therapy on the basis of which the well known Oral Rehydration Solution (ORS) had been formulated. The Cholera Research Laboratory was transformed into International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in 1979 with a field study station of 200,000 population located in rural Bangladesh. This large population was under constant demographic surveillance, the outcome led to the drugs and vaccines and many other significant and often pioneering research activities in community medicine. It was here that the community efficacy of ORS was formally established as an intervention of profound value with the potential to save millions of lives if used properly. The intervention was quite appropriately termed as the one of most significant medical discoveries of the twentieth century. Today icddr,b spends a large parts of its resources on health projects directly targeted at the community.
Another pioneering institution in community medicine is the Bangladesh Institute for Research and Rehabilitation in Diabetic Endocrine and Metabolic Disorders (birdem) founded in 1980. It is an organ of the diabetic association of bangladesh (DAB) and a 'WHO Collaborating Centre for control of diabetes. Although its primary focus is to serve 4 million diabetic patients, it also addresses total health care issues. At the community level DAB has 46 affiliated societies working throughout the country.
At present many non-government organisations (NGOs) in Bangladesh are involved in community research activities. For instance, Bangladesh Rural Advancement Committee (brac), an internationally reputed national NGO of the country being the world largest, works on field application of oral rehydration therapy, making cost-effective home treatment available to communities using home ingredients such as salt and molasses dissolved in water, a formulation locally called 'lobon-gud'. The organisation has programmes on TB therapy where a common problem is that the patients often discontinue the rather long (one year) treatment schedule. Experimental field research was initiated by BRAC that included provision of incentives to participating patients. Patients are required to deposit a token sum of money (Taka 100, roughly equivalent to $ 2) towards treatment cost most of which is returned at the end of the completion of the treatment. This increased treatment completion rate and provided great benefit to individuals and the community.
Many NGOs in Bangladesh are at present involved in health care activities at the community level. Areas where community medicine projects are being implemented in Bangladesh include vitamin A deficiency, arsenic-toxicity, diarrhoeal diseases, goitre, intestinal parasites, and immunisation programmes for children.
Community medicine is likely to contrive as a high priority area of medicine in Bangladesh. Population projections suggest that there will be about 250 million people by the middle of the present century. That is, the country will have to cope with a population density of nearly 1700 persons per square kilometre. The rural communities will have some typical rural problems characteristic of a poor economy, poor sanitation, inadequate safe drinking water, high infectious disease load, problems related to nutrition, environmental degradation, as well as over-crowding at the household level. There can no better cost-effective health intervention than those aimed at the community as a whole that will reduce preventable disease burdens and allow individuals to reap the benefit of the limited health resources of the country.
Community-based medical colleges and similar educational institutions in the health sciences have been established in recent years in rural setting in the private sector. These institutions are suitably poised to involve the community in health matters through direct participation of its members. Health education can substantially reduce the incidence of many common infectious diseases, and abolish many others altogether through successful immunisation programmes. The emphasis that the discipline of community medicine receives these days from the medical community is exemplified by the fact that some private universities of the country are now offering courses in community medicine. Recent government decision to establish a community health centre at every word or village level will be of great benefit in the health care system of our country. [Zia Uddin Ahmed]