Social Medicine as a science - subject matter, objectives and methods

Social medicine is the study of people as social beings in their total environment, with the health of the community as a whole as its focus. It is a complex, integrative science whose object is public health as a whole system, and it is also a clinical discipline because it studies health and disease. Its subject matter is population health as a complex system; its objectives are to describe the state of that health, to organise and manage its promotion, to prevent disease and to help people with disabilities take their place in society. It works with the methods of other sciences, above all sociology, epidemiology, economics and bioethics, and it uses the historical method to compare how public health has changed over time.

What social medicine is

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. It is not a new branch of medicine but a new orientation of medicine towards the changing needs of man and society, and it emphasises the strong relationship between medicine and the social sciences.

Social medicine is a complex and integrative science. Its object is public health as a whole system. It is also a clinical discipline, because it studies health and disease. It is not a traditional science but a new integrative one, whose task is to study public health as a whole system, with its elements and the relationships between its components.

Put in one sentence, the discipline is a complex integrative science that consolidates the knowledge of medical and social sciences and focuses on population health as a complex subject. It studies health at population level.

The object of study

The subject of social medicine is population health as a complex systemic object. Its area of application is public health. It studies four groups of problems: social aetiology (the social causes of disease), social pathology (the social course of disease), social therapy and social prevention.

Social medicine has two parts:

1. The fundamental part describes and analyses the status and trends of population health.
2. The practical part is concerned with how the health system functions, with developing programmes and initiatives that promote population health, and with managing the public health system.

Connections with other disciplines

Social medicine is interdisciplinary. It uses the methods of different sciences, such as economics, bioethics, epidemiology and sociology, and of others. Its connections with the other clinical and medico-biological disciplines can be seen in the areas it is interested in:

• public health, and the health of specific risk groups such as disabled persons, family planning, and ethnic groups;
• the health relation between the individual and society as a whole;
• the different social effects that can influence the health of an individual;
• individual and group health, the health of the population as a whole, and the connection between them;
• the structure and dynamic tendencies of public health.

Social medicine gives the theoretical aspects of public health. It is an open functional system that gives ideas to other clinical and humanitarian sciences. It develops health policies and health management, and it is important for health research and for genetic research.

Medical sociology and social medicine

Medical sociology is a specialisation within the field of sociology. Sociology is the science that studies the structure, functioning and development of society as a system. Medical sociology studies health, health behaviour and medical institutions. Its interests include the cultural factors and social relations connected with illness, the social principles of medical organisation and treatment, the medical profession, the relation of medicine to public health, and the social factors in the aetiology, prevalence, incidence and interpretation of disease. As a specialised field it was first proposed by Charles McIntire in 1894.

The lectures state the purpose of the discipline in practical terms. Social medicine gives the methodology for organising and managing:

• the promotion of public health;
• the prevention of disease;
• recovery from disease;
• the social integration of patients with disabilities into society.

Its main objectives are these:

1. To understand health inequalities: to analyse why health disparities exist between different social groups and between geographical areas.
2. To promote health equity: to make sure that all people have fair access to health care and to the means of keeping well.
3. To prevent socially determined illness: to reduce the number of diseases caused or made worse by social and economic conditions.
4. To influence health policy: to develop evidence-based policies that improve public health outcomes and address the social determinants of health.

The objects of social medicine can also be listed as follows:

Social medicine takes a holistic view of health. It recognises the connections between individuals and their social environments, and it aims to create conditions that support health and well-being for everyone in society.

The lectures present two basic methods of social medicine: the historical method and the sociological method. Social medicine also uses epidemiological and statistical methods, and methods of analysing policy.

The historical method

The historical method compares the tendencies of public health in the past and at present, and uses that comparison to build a better future. The history of medicine reviews accomplishments and errors, false theories and misinformation, and mistaken interpretations. It studies the evolution of man and of human knowledge through the ages, through:

• the biographies of eminent individuals who developed medicine;
• the discoveries and inventions of different historical periods;
• the ever-changing concepts, goals and objectives of medicine.

Medical knowledge has been derived, to a great degree, from intuitive and observational propositions and from the cumulative experience gleaned from others. Medicine has moved forward in stages, with advances and halts. It has drawn on traditional cultures, later on the biological and natural sciences, and more recently on the social and behavioural sciences. Medicine is thus built on the best of the past. The history of the ideas of medicine is set out in section 5.

The sociological method

Basic methods in sociology provide primary descriptive information. That information is analysed statistically and is the foundation for conclusions about a problem at the level of the whole group. The methods are matched to the source of the information:

• Questionnaire. The questionnaire is the main tool of the survey. Information is collected by the respondents answering, in writing, questions that are given on a printed questionnaire. The questionnaire must reflect the purpose of the study, and its questions are its most important part. Questions can be grouped by their place and role in the questionnaire, by the way they are formulated, and by the way the answer is given. The method can reveal opinions, intentions, plans, moods, motives for reactions, views, and the social position and role of the people questioned.
• Interview. An interview is a scientific procedure with direct oral contact between two or more people, in which personal information needed for a scientific problem is obtained first hand. It is a process of verbal communication used to obtain valid personal information. The answers are written down. The interviewer needs a deep background in sociology and psychology to create an atmosphere of trust and honesty, and a second session can be held if needed. Interviews are classed by the kind of questions asked, by the number of people interviewed, and by the number of interviews. A structured (formal, guided) interview uses predetermined questions. It takes less time, does not use the respondent's own words, and interviewer bias is possible. An unstructured (informal, open-ended) interview explores particular topics rather than specific questions. It gives less biased information and detailed information on the theme studied, but not every respondent gives the same information and it takes more time. Interviews can be conducted by telephone, face to face, by video recording or by audio recording.
• Observation. The behaviour of a person, or his reactions in a certain situation, is observed and recorded. Observation is classed by the way the observer communicates with the observed person, by the level of confidentiality, and by the number of observations. A simulated observation takes place in a specially created situation.
• Analysis of documents. Documents are examined as the source of information about the subject.

The epidemiological method

Epidemiology is a set of studies made upon people. It studies groups of people rather than individuals, and it increases understanding of how diseases and other health-related events arise and how they can be managed, both for the individual and for society as a whole. Its aims are to describe the distribution of disease, to identify risk factors, and to provide the data needed for the prevention, control and treatment of disease.

Statistical analysis and policy analysis

Social medicine analyses quantitatively the data from studies, surveys and health records to identify trends and correlations. It also uses community-based participatory research, in which communities take part in the research so that their needs and views shape the study and the interventions that follow. Policy analysis assesses the impact of policies on public health and supports changes that reduce inequalities and improve health outcomes.

The idea that social factors shape disease was put forward before the name was revived. Neumann (1847) and Virchow (1848) were pioneers of the idea, but it was ahead of its time. The germ theory of disease and the discoveries in microbiology held the development of these ideas back.

In 1911 Alfred Grotjahn of Berlin revived the concept. He stressed the importance of social factors in the aetiology of disease and called this social pathology. Others called it geographical pathology or population pathology. In 1912 René Sand founded the Belgian Social Medicine Association. The ideas spread to other countries; John Ryle and his group in England were influenced by them and saw social medicine as an evolution of medicine.

Development in this field rediscovered that man is not only a biological being but also a social one, and that disease has social causes, social consequences and social therapy.

Social medicine in Bulgaria

The discipline has changed its name several times in Bulgaria:

The names of the discipline depend on the requirements of the people, the level of knowledge in society, the status of social policy in the country, administration and health management, and the different names used in developed countries.

Primitive and supernatural medicine

Early man attributed disease, and all human suffering and calamity, to the wrath of the gods, to the invasion of the body by evil spirits, and to the harmful influence of stars and planets. This is the supernatural theory of disease. In prehistoric times, about 5000 BC, medicine was mixed with superstition, religion, magic and witchcraft. The medicine man, the priest, the herbalist and the magician all tried to cure disease and relieve the sick. Primitive medicine persists in parts of Asia, Africa, South America, Australia and the Pacific islands. Medicine in those early times was dominated by magical and religious beliefs, which were an integral part of ancient cultures and civilisations. Although there was an almost complete absence of scientific medical knowledge, it would not be fair to say that the early practitioners contributed nothing to relieving human suffering.

Ancient India

The medical systems that are truly Indian in origin are Ayurveda and Siddha. The two systems differ little in theory and practice.

The Vedic period is the time in which the Vedas, the oldest sacred texts of the Indo-Aryans, were composed. Its culture was centred in the northern and north-western parts of the Indian subcontinent. Its early phase saw the formation of many kingdoms; in its late phase, from about 600 BCE, it saw the rise of the Mahajanapadas, and it was followed by the Maurya Empire (from about 320 BCE), the golden age of classical Sanskrit literature. Linguistically the Vedic texts fall into five chronological strata:

1. Rigvedic: the Rigveda, by far the most archaic of the Vedic texts, which retains many Indo-Iranian elements in language and content.
2. Mantra language: the mantra and prose language of the Atharvaveda, the Rigveda Khilani, the Samaveda Samhita and the mantras of the Yajurveda.
3. Samhita prose: the beginning of the collection and codification of a Vedic canon.
4. Brahmana prose: the Brahmanas proper of the four Vedas.
5. Sutra language: the last stratum of Vedic Sanskrit, leading up to about 500 BCE.

Ayurvedic practitioners identified many medicinal preparations and surgical procedures for curing ailments. In the Western world Ayurveda is regarded as a form of complementary and alternative medicine, and its herbs, massage and yoga are used on their own. Similar approaches also exist in Unani, Greek and Islamic medicine.

• Ayurveda means the knowledge of life, or the knowledge by which life may be prolonged. In Sanskrit the word joins ayus (life) and veda (knowledge or science). The lectures date its origin to the Vedic times, about 5000 BC, and also give the Vedic period as the second and first millennia BCE, continuing to the 6th century BCE. The Ayurvedic literature is traced to the Vedic period on literary evidence, and its medical history was associated with mythological figures, sages and seers. The Vedas are the oldest sacred texts of the Indo-Aryans. Ayurveda is grounded in five great elements (earth, water, fire, air and ether), which make up the universe including the human body. Traditional beliefs hold that humans possess a unique constellation of doshas. It stresses a balance of three substances or doshas: vata (wind, spirit or air), pitta (bile) and kapha (phlegm).
• The tridosha theory explains disease as a disturbance in the equilibrium of the three humours. When they are in perfect balance and harmony the person is healthy. This theory is strikingly similar to the theory of four humours in Greek medicine.
• Vata is the most important dosha. It dominates the part of the body below the umbilicus, and it assists the movement of body fluids, metabolism, the elimination of waste, semen ejaculation, the pushing of the foetus out of the body, the relaying of stimuli to the brain, the heartbeat, respiration and body movement.
• Pitta assists the body fire (agni), which drives the body's metabolic activity. Pitta dominates in the digestive system, skin, eyes, brain and blood, and maintains body temperature.
• Kapha provides bulk, lubrication, moistness, fertility, stability, strength and memory, and helps in binding processes wherever needed. It is the heaviest of the doshas, and it dominates the chest, neck, head, stomach, body fat, nose and tongue.
• Siddha is the other Indian system. Its sages were called Siddhars in the South (the Rishis in the North). The Siddhars classified the diseases of the body by topic and counted 4448 diseases. The lecture says that the Siddha teaching was passed from Lord Siva to Matha and Sri Parasakthi. The lecture also presents the system as having no side effects and as suitable for the whole family; these are claims made in the lecture and are not medical findings. They described curable and incurable diseases, their symptoms and the medicines they considered proper. The Siddha system holds the slogan "Food is medicine and medicine is food".
• The leading authorities of Ayurveda were Atreya, Charaka, Sushruta and Vaghbhatt. Atreya (about 800 BC) is acknowledged as the first great Indian physician and teacher. Ayurveda flourished during the Buddhist period.
• Charaka compiled his treatise, the Charaka Samhita. The lectures give his date as 200 AD in one place and as c. 300 BC in another, and describe him as the father of anatomy. He mentions 500 drugs. He was the first physician to present the concepts of digestion, metabolism and immunity. He taught that illness comes when the balance of the three doshas is disturbed, and he prescribed drugs to restore the balance. He knew the fundamentals of genetics: he said that a genetic defect such as lameness or blindness is due to the ovum or sperm of the parents, not to a defect of either parent. He was born around 300 BC in a Maga Brahmin family, and he is sometimes spelled Caraka. He was aware of germs but did not give them importance. He knew the factors that determine the sex of a child, and he taught that a genetic defect such as lameness or blindness comes from the ovum or sperm of the parents, not from any defect in the mother or father. He gave 360 as the number of bones in the body, including the teeth, and he wrongly believed that the heart had one cavity, but he correctly saw it as the controlling centre of the body. He also taught that a physician must understand the environment that influences a patient's disease before prescribing treatment, and that preventing disease is more important than curing it.
• Sushruta is known as the father of Indian surgery. He compiled the surgical knowledge of his time in the Sushruta Samhita. The lectures date the work between 800 BC and 400 AD and, in another place, give Sushruta as a sage physician of the 6th century BC in Varanasi. The text as preserved dates to the 3rd or 4th century AD. The Bower Manuscript holds some of the most important information on the early Ayurvedic documents. Surgery was considered the most important of the eight branches of medical knowledge. The text was translated into Arabic in the 8th century. It contains 184 chapters, descriptions of 1120 illnesses, 700 medicinal plants, a detailed study of anatomy, 64 preparations from mineral sources and 57 from animal sources.
• Charaka's and Sushruta's samhitas were translated into Persian and Arabic about 800 AD. Medical historians admit that there was a free exchange of thought and experience between Hindu, Arab, Persian, Greek and Jewish scholars. Indian medicine played in Asia the role that Greek medicine played in the West: it spread to Indonesia, Tibet, Central Asia and as far as Japan.
• Other systems in India. Unani-Tibb has its origin in ancient Greek medicine and was introduced into India by Muslim rulers about the 10th century AD. Homoeopathy was propounded by Samuel Hahnemann (1755-1843) of Germany. It is a system of pharmacodynamics based on the treatment of disease with small amounts of a drug that, in healthy people, produces symptoms similar to those of the disease treated. Homoeopathy gained ground in India between 1810 and 1932, according to the lectures. India has the largest number of homoeopathic practitioners in the world. The Indian systems, including Unani-Tibb and Homoeopathy, are still alive in India and remain an important source of medical care for the rural population.
• Buddhism is a religion or spiritual philosophy based on the life and teaching of Siddhartha Gautama, the Buddha, who taught a path to the end of suffering and to nirvana. The foundation of all Buddhist practice is ethical conduct and altruism. Its two main branches are Theravada ("The School of the Elders"), which is the oldest surviving and is followed in Sri Lanka and South-East Asia, and Mahayana ("The Great Vehicle"), which is found throughout East Asia. Buddhism is attained through insight into the ultimate nature of reality. Adherents recognise the Buddha as an awakened teacher who shared his insights to help living beings end suffering, achieve nirvana and escape the cycle of suffering and rebirth. Mahayana includes the traditions of Pure Land, Zen, Nichiren Buddhism, Tibetan Buddhism, Shingon, Tendai and Shinnyo-en. Practice may include renunciation, meditation, the cultivation of mindfulness and wisdom, the study of scriptures, physical exercises, devotion and ceremonies, or the invocation of bodhisattvas. The Buddha spent the rest of his life teaching the path he had discovered, travelling through the north-eastern part of the Indian subcontinent. He died at the age of 80 in Kushinagar, India (483 BCE). Estimates of the number of Buddhists in the world range from 230 million to 500 million.

Ancient China

Chinese medicine, dating back to 2700 BC, is based on two principles: the yang, an active masculine principle, and the yin, a negative feminine principle. Good health is the balance of these two opposing forces. Chinese physicians used hygiene, dietetics, hydrotherapy, massage and drugs. The Chinese were early pioneers of immunisation. In their view the great doctor treats the person who is not yet ill. Chinese traditional medicine is fully integrated with modern medicine, and the Chinese have great faith in it.

Ancient Egypt

Egypt had one of the oldest civilisations, about 2000 BC. The art of medicine was mingled with religion, but it was far from primitive. Egyptian medicine reached its peak in the days of Imhotep (2800 BC). Specialisation prevailed: there were eye doctors, ear doctors and tooth doctors, all of them officials paid by the state. Physicians believed that the pulse was the speech of the heart. Diseases were treated with purgatives, enemas, blood-letting and a wide range of drugs.

The best known medical manuscripts are these:

• the Edwin Smith papyrus (3000-2500 BC), the oldest treatise on surgery, which accurately describes partial paralysis following cerebral lesions in skull fractures;
• the Ebers papyrus (1150 BC), found with a mummy, which is a unique record of prescriptions based on some 700 drugs.

In public health the Egyptians excelled. They built planned cities, public baths and underground drains that the modern world might envy, and they had some knowledge of inoculation against smallpox. Egyptian medicine held a dominant place in the ancient world for about 2500 years, until it was replaced by Greek medicine.

Ancient Greece

The classic period of Greek medicine was 460 to 136 BC. The Greeks enjoyed the reputation of being the civilisers of the ancient world. The Greeks taught men to think in terms of "why" and "how", and they gave medicine a new direction. They rejected the supernatural theory of disease and looked on disease as a natural process.

• Aesculapius (about 1200 BC) was an early leader in Greek medicine. His daughters were Hygiea, worshipped as the goddess of health, and Panacea, the goddess of medicine. Their two roles gave rise to curative medicine and preventive medicine, and the split between the two has lasted to the present day.
• Hippocrates (460-370 BC) is called the Father of Medicine. He studied and classified diseases by observation and reasoning, challenged magic in medicine, and introduced the clinical method. His lectures and writings were compiled by Alexandrian scholars into the Corpus Hippocraticum, a 72-volume work that contains the first scientific clinical case histories. The Hippocratic Oath has become the keystone of medical ethics.
• Hippocrates was also the first true epidemiologist. He was constantly seeking the causes of disease, and he studied climate, water, clothing, diet and the habits of eating and drinking. He initiated a radically new approach to medicine, and he will always be regarded as one of the masters of the medical art. He distinguished between epidemic and endemic diseases, and he studied climate, water, clothing, diet, eating and drinking habits and their effect on disease.
• The Greeks believed that matter was made of four elements, earth, air, fire and water, which had the qualities of cold, dry, hot and moist. In the body they were represented by four humours: phlegm, yellow bile, blood and black bile. Health prevailed when the four humours were in equilibrium, and disease was the result of imbalance. This is similar to the tridosha theory of Ayurveda.
• In the post-Hippocratic period the museum of Alexandria, the first university in the world, held a library of over 70 000 books. Between 300 and 30 BC thousands of pupils studied at its school, which replaced Athens as the world's centre of learning.

Ancient Rome

The glorious Greek civilisation fell into decay and was succeeded by the Roman civilisation. The Romans were more practical than the Greeks and had a keen sense of sanitation. Public health was born in Rome with the development of baths, sewers and aqueducts. The Romans built fine roads throughout their empire, brought pure water to their cities by aqueducts, drained marshes to combat malaria, built sewerage systems, and established hospitals for the sick.

The most important Roman medical teacher was Galen (130-205 AD). He was far ahead of his time. He held that health comes first, both in importance and in time, so we should first consider how health may be preserved and then how disease may best be cured. He observed that disease is due to three factors: predisposing, exciting and environmental factors. This is a truly modern idea. Galen wrote some 500 treatises on medical subjects and was a medical authority in his time. His writings were standard textbooks in medicine for 14 countries until his views were challenged by the anatomist Vesalius in 1543 and by the physiologist William Harvey in 1628, almost 1500 years after Galen's death.

The Middle Ages

The period between 500 and 1500 AD is generally known as the Middle Ages. With the fall of the Roman Empire the medical schools of Roman times disappeared, and medicine reverted to a primitive form dominated by superstition and dogma. This is why the period is called the Dark Ages of medicine.

• The Arabs preserved the ancient knowledge. They translated the Greco-Roman medical literature into Arabic and founded schools of medicine and hospitals in Baghdad, Damascus, Cairo and other Muslim capitals.
• The leaders of Arabic medicine included the Persians Abu Bakr (865-925) and Ibn Sina (980-1037), known to the West as Avicenna. Ibn Sina compiled a 21-volume encyclopaedia, the Canon of Medicine.
• During the Middle Ages religious institutions known as monasteries, headed by monks, saints and abbots, admitted men and women from all ranks, including kings and queens. They preserved ancient knowledge and gave active medical and nursing care to the sick.

The revival of medicine

The period after 1500 AD was marked by political, industrial, religious and medical revolutions. For many historians the revival of medicine covers the years 1453 to 1600, an age of individual scientific endeavour.

• Paracelsus (1493-1541), a Swiss physician, revived medicine and turned it towards rational research.
• Fracastoro (1483-1553), an Italian physician, put forward the theory of contagion.
• Andreas Vesalius (1514-1564) raised the study of anatomy to a science and is called the first man of modern science. His great work, the Fabrica, became a classic textbook of anatomy in medical education.
• Ambroise Paré (1510-1590), a French army surgeon, earned the title father of surgery.
• The 17th and 18th centuries brought Harvey's discovery of the circulation of blood (1628), Leeuwenhoek's microscope (1670) and Jenner's vaccination against smallpox (1796).

Historical method, as the lectures put it, compares the tendencies of public health in the past and the present and uses this comparison for a better future. The history of medicine is the record of these stages.