Scot. med, J., 1976. 21: 4
WHAT IS COMMUNITY MEDICINE When the Editor of this Journal asked me to answer this question, he was voicing an uncertainty which is very widespread. There never was any question about what Public Health was-and presumably still is-nor is there any doubt that practitioners of medicine must serve their community as well as their patients. The question in many minds is whether there is any need to differentiate as a separate branch of medicine a philosophic concept which is manifestly a collective responsibility of all branches of medical practice. If all is said and everything is done, who could be said to do more for the community than a good general practitioner, a geriatrician, a child health specialist or, in the outmoded pre-1974 terminology, a medical officer of health. What has community medicine to offer, apart from fine words, that all these other branches of medicine in their diversity and centuries of service are not already offering? So the question is a fair one, highly topical at a time when medicine itself as a discipline is undergoing self-scrutiny and re-appraisal about its place in the community. In some respects, the emergence of community medicine is a reflection of this re-appraisal, gaining prominence less as a speciality than as a symbol of re-orientation of all of medicine and of allied professions toward the needs of the community which, in many respects, are unmet or inadequately met by traditional forms of medical practice. It has to be admitted, as a first step in reappraisal, that medicine has geared itself in the past mainly towards episodic care of illness with much less emphasis upon prevention, health education, counselling, rehabilitation and maintenance of health generally. It has also concentrated its resources increasingly upon hospital-based investigation, technology and terminal illness, to such an extent that hospitals consume 70 per cent of national expenditure on 'health' in most countries while drugs and palliative procedures often of questionable value consume about 10 per cent more. This leaves usually less than 20 per cent for all other purposes, including general practice, preventive medicine and dentistry. For instance in Scotland, where teeth are probably worse
than in any other country, dental services collectively get less than 4 per cent of the health budget while the school dental service verges on disappearance. The most common cause of sickness in the U.K. by far is respiratory disease. The cost to the health service for palliative treatment of respiratory disease is enormous, while the cost to the country in loss of 70 million or more working days every year under this heading is incalculable. Yet the amount spent on primary prevention is fractional. In terms of what is needed in the community, there should be, therefore, no question about what is community medicine: it is and always has been (Hippocrates, 1964) self-defining as a special effort by the medical profession to redress imbalance by recognising the need to coordinate medical care with health maintenance. The pioneers of social medicine-men like John Snow, Joseph Lister, John Ryle and James Spence-were practical doctors who perceived this need. Their successors, charged with responsibility today for the effort, are doctors who have elected to specialise in the wider problems of community health rather than in the narrower problems of individual sickness or mechanisms of disease. Whether all who have now elected for this option as a speciality are fit for the wider task is another question, but there should be no question about what has to be done or about the sincerity with which, in somewhat excessively general terms, the challenge is being approached in all parts of the world (W.H.O., 1975). In the U.K., the Goodenough Report in 1944 (Interdepartmental Committee on Medical Schools 1944) felt that 'ideas of social medicine must permeate the whole of medical education'. The Royal Commission on Medical Education (Todd Report, 1968) called upon medical schools to establish departments or divisions of community medicine concerned with all aspects of the subject. In many parts of the world, especially in Scotland and in English provincial universities, all this has been going on for a century or longer (Gald ston, 1954) in the form of courses and practical instruction in public health and preventive medicine which were required as subjects for professional examinations for their M.B. degrees (W.H.O., 1975). Acceptance of
Downloaded from scm.sagepub.com at SAGE Publications on June 21, 2016
Leading Articles
the Todd Report led to an extension of teaching in academic departments until eventually in 1974 the University of London approved social and preventive medicine as examination subjects for the M.B. London. Meanwhile, other anomalies began to be corrected. Historically, community medicine in its earlier guise of public health had usually proceeded on parallel but separate tracks from clinical work (Williams, 1932), often with absurd gaps between them, as in the child health and hospital paediatric services. In the U.K. the N.H.S. Act of 1948 belied its name by excluding Public Health and by providing what was essentially a sickness service, humane and comprehensive in concept but lacking in commitment to health maintenance and preventive medicine. The reorganisation Bills of 1972, enacted with effect from 1st April 1974, made the N.H.S. in the U.K. comprehensive in the administrative sense by integrating public health, general practice and hospital medicine. In parallel with this reorganisation, the Royal Colleges of Physicians sponsored a Faculty of Community Medicine. So, by Act of Parliament and by decree if not by degree, Community Medicine had arrived. Medical Officers of Health, administrative medical officers, medical superintendents and various others all became specialists in community medicine, almost overnight. In drawing attention to 'all aspects' of community medicine as an essential part of medical education, the Todd Commission was looking for 'the means of providing health services for the whole population' with recognition of related social and economic problems and of the contributions of general practice, hospitals and various other services toward this end. The basicdisciplines of community medicine serve this end by including not only epidemiology, biostatistics and environmental health, as before, but also enough social science, demography and economics to make it into an effective new discipline for planning, delivering and evaluating health care. On this basis, doctors receiving postgraduate training and recognition as specialists in community medicine are expected to take a guiding if not a leading role, centrally and peripherally, in co-
ordinating all branches of the health services. Conditions for qualifying as specialists in many countries are now regulated. In the U.K. specialisation begins with intensive practical as well as academic training after a minimum of 2 years' postgraduate experience in clinical work (Royal College of Physicians, 1974). With increasing attention to health education and to strategy based on shoe leather and clinical epidemiology, there is a widespread hope that community medicine might emerge as a discipline which will restore a sense of proportion and humanism to a medical world which has become overstretched by technology and narrow specialisation. In this respect, community medicine is an advance in concept at least from latter-day (i.e. post 1948) public health. Whether it will be an advance in practice remains to be seen. Increasing emphasis upon medical administration carries more than a hint of entanglement of everyone in a bureaucratic network. Current reorganisation, like any other, provides opportunities for power play and opportunism. Hence the outcome may depend much less upon theoretical than upon human factors. Since the question has been posed, in this of all subjects, the obvious epidemiological answer in any cohort study should be remembered: community medicine is at present in the hands of a cohort of middle-aged and elderly men; its future might best be viewed as the open-ended outcome of interaction between old Turks (like the writer) and the young Turks whose refreshing advent we eagerly await. GORDON T. STEWART. REFERENCES Galdston,I. (1954). The Meaning of Social Medicine. Cambridge, Mass: Harvard University Press Goodenough Report. (1944). Report of Interdepartmental Committee on Medical Schools. London: H.M. Stationery Office Hippocrates. (1964). Theory and Practice of Medicine. New York: Citadel Press, Royal College of Physicians. (1974). Specialist Training in Community Medicine. Faculty of Community Medicine Todd Report. (1968). Royal Commission on Medical Education 1965-68.London; H. M. Stationery Office W.H.O. (1975). Chronicle, 29, 1 Williams, H. (1932). A Century of Public Health in Britain. London: A. & C. Black 5
Downloaded from scm.sagepub.com at SAGE Publications on June 21, 2016
WHAT IS COMMUNITY MEDICINE When the Editor of this Journal asked me to answer this question, he was voicing an uncertainty which is very widespread. There never was any question about what Public Health was-and presumably still is-nor is there any doubt that practitioners of medicine must serve their community as well as their patients. The question in many minds is whether there is any need to differentiate as a separate branch of medicine a philosophic concept which is manifestly a collective responsibility of all branches of medical practice. If all is said and everything is done, who could be said to do more for the community than a good general practitioner, a geriatrician, a child health specialist or, in the outmoded pre-1974 terminology, a medical officer of health. What has community medicine to offer, apart from fine words, that all these other branches of medicine in their diversity and centuries of service are not already offering? So the question is a fair one, highly topical at a time when medicine itself as a discipline is undergoing self-scrutiny and re-appraisal about its place in the community. In some respects, the emergence of community medicine is a reflection of this re-appraisal, gaining prominence less as a speciality than as a symbol of re-orientation of all of medicine and of allied professions toward the needs of the community which, in many respects, are unmet or inadequately met by traditional forms of medical practice. It has to be admitted, as a first step in reappraisal, that medicine has geared itself in the past mainly towards episodic care of illness with much less emphasis upon prevention, health education, counselling, rehabilitation and maintenance of health generally. It has also concentrated its resources increasingly upon hospital-based investigation, technology and terminal illness, to such an extent that hospitals consume 70 per cent of national expenditure on 'health' in most countries while drugs and palliative procedures often of questionable value consume about 10 per cent more. This leaves usually less than 20 per cent for all other purposes, including general practice, preventive medicine and dentistry. For instance in Scotland, where teeth are probably worse
than in any other country, dental services collectively get less than 4 per cent of the health budget while the school dental service verges on disappearance. The most common cause of sickness in the U.K. by far is respiratory disease. The cost to the health service for palliative treatment of respiratory disease is enormous, while the cost to the country in loss of 70 million or more working days every year under this heading is incalculable. Yet the amount spent on primary prevention is fractional. In terms of what is needed in the community, there should be, therefore, no question about what is community medicine: it is and always has been (Hippocrates, 1964) self-defining as a special effort by the medical profession to redress imbalance by recognising the need to coordinate medical care with health maintenance. The pioneers of social medicine-men like John Snow, Joseph Lister, John Ryle and James Spence-were practical doctors who perceived this need. Their successors, charged with responsibility today for the effort, are doctors who have elected to specialise in the wider problems of community health rather than in the narrower problems of individual sickness or mechanisms of disease. Whether all who have now elected for this option as a speciality are fit for the wider task is another question, but there should be no question about what has to be done or about the sincerity with which, in somewhat excessively general terms, the challenge is being approached in all parts of the world (W.H.O., 1975). In the U.K., the Goodenough Report in 1944 (Interdepartmental Committee on Medical Schools 1944) felt that 'ideas of social medicine must permeate the whole of medical education'. The Royal Commission on Medical Education (Todd Report, 1968) called upon medical schools to establish departments or divisions of community medicine concerned with all aspects of the subject. In many parts of the world, especially in Scotland and in English provincial universities, all this has been going on for a century or longer (Gald ston, 1954) in the form of courses and practical instruction in public health and preventive medicine which were required as subjects for professional examinations for their M.B. degrees (W.H.O., 1975). Acceptance of
Downloaded from scm.sagepub.com at SAGE Publications on June 21, 2016
Leading Articles
the Todd Report led to an extension of teaching in academic departments until eventually in 1974 the University of London approved social and preventive medicine as examination subjects for the M.B. London. Meanwhile, other anomalies began to be corrected. Historically, community medicine in its earlier guise of public health had usually proceeded on parallel but separate tracks from clinical work (Williams, 1932), often with absurd gaps between them, as in the child health and hospital paediatric services. In the U.K. the N.H.S. Act of 1948 belied its name by excluding Public Health and by providing what was essentially a sickness service, humane and comprehensive in concept but lacking in commitment to health maintenance and preventive medicine. The reorganisation Bills of 1972, enacted with effect from 1st April 1974, made the N.H.S. in the U.K. comprehensive in the administrative sense by integrating public health, general practice and hospital medicine. In parallel with this reorganisation, the Royal Colleges of Physicians sponsored a Faculty of Community Medicine. So, by Act of Parliament and by decree if not by degree, Community Medicine had arrived. Medical Officers of Health, administrative medical officers, medical superintendents and various others all became specialists in community medicine, almost overnight. In drawing attention to 'all aspects' of community medicine as an essential part of medical education, the Todd Commission was looking for 'the means of providing health services for the whole population' with recognition of related social and economic problems and of the contributions of general practice, hospitals and various other services toward this end. The basicdisciplines of community medicine serve this end by including not only epidemiology, biostatistics and environmental health, as before, but also enough social science, demography and economics to make it into an effective new discipline for planning, delivering and evaluating health care. On this basis, doctors receiving postgraduate training and recognition as specialists in community medicine are expected to take a guiding if not a leading role, centrally and peripherally, in co-
ordinating all branches of the health services. Conditions for qualifying as specialists in many countries are now regulated. In the U.K. specialisation begins with intensive practical as well as academic training after a minimum of 2 years' postgraduate experience in clinical work (Royal College of Physicians, 1974). With increasing attention to health education and to strategy based on shoe leather and clinical epidemiology, there is a widespread hope that community medicine might emerge as a discipline which will restore a sense of proportion and humanism to a medical world which has become overstretched by technology and narrow specialisation. In this respect, community medicine is an advance in concept at least from latter-day (i.e. post 1948) public health. Whether it will be an advance in practice remains to be seen. Increasing emphasis upon medical administration carries more than a hint of entanglement of everyone in a bureaucratic network. Current reorganisation, like any other, provides opportunities for power play and opportunism. Hence the outcome may depend much less upon theoretical than upon human factors. Since the question has been posed, in this of all subjects, the obvious epidemiological answer in any cohort study should be remembered: community medicine is at present in the hands of a cohort of middle-aged and elderly men; its future might best be viewed as the open-ended outcome of interaction between old Turks (like the writer) and the young Turks whose refreshing advent we eagerly await. GORDON T. STEWART. REFERENCES Galdston,I. (1954). The Meaning of Social Medicine. Cambridge, Mass: Harvard University Press Goodenough Report. (1944). Report of Interdepartmental Committee on Medical Schools. London: H.M. Stationery Office Hippocrates. (1964). Theory and Practice of Medicine. New York: Citadel Press, Royal College of Physicians. (1974). Specialist Training in Community Medicine. Faculty of Community Medicine Todd Report. (1968). Royal Commission on Medical Education 1965-68.London; H. M. Stationery Office W.H.O. (1975). Chronicle, 29, 1 Williams, H. (1932). A Century of Public Health in Britain. London: A. & C. Black 5
Downloaded from scm.sagepub.com at SAGE Publications on June 21, 2016
