Public Health and Community Medicine

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Public Health and Community Medicine

Editor Muhammad Irfanullah Siddiqui

MBBS (Dow), MPH, MCPS, M Phil (BMU), FCPS, Former Dean, Faculty of Health Sciences, Baqai Medical University. Former Vice Principal, Bahria University Medical and Dental College Former Chairman, Hamdard College of Medicine & Dentistry, Hamdard University Currently Professor at Umm Al-Qura University, Makkah Mukarramah, KSA

Associate Editors Shahida Rasheed

MBBS , MPH, MCPS, FCPS, Professor, Chairperson, Department of Community Health Sciences, Ziauddin University, Karachi

Iftikhar Ahmed Khan

B.Sc., MBBS, DPH Professor & Chairman, Department of Community Health Sciences, Gandhara University Medical College, Peshawar. Former, Professor & Head, Department of Community Medicine, Khyber Medical College, Peshawar

Ghulam Qadir Malik

MBBS(Pb.), MD, DCH, DPH Professor & Chairman, Department of Community Medicine, Frontier Medical College, Abbottabad. Former, Professor & Chairman, Department of Community Medicine, Nishtar Medical College, Multan.

Inayat H. Thaver

MBBS, MSc. MCH (London), MCPS, FCPS, Ph.D (London) Consultant, British High Commission, Islamabad. Former Consultant, United Nations Fund for Population Activity. Former Dean Faculty of Health Sciences, Baqai Medical University.

S.N. Bazmi Inam

MBBS, MPH (USA), FCPS Former Professor & Chairman, Department of Community Health Sciences, Ziauddin University, Karachi Professor, Department of Community Medicine, Qaseem University, KSA

Prof. Lubna Baig

Dean, APPNA Institute of Public Health Jinnah Sindh Medical University, Karachi.

Mahmuda Mubasher

Professor & Head, Department of Community Medicine, Lahore Medical College, Lahore. Farida Habib Khan FCPS, MPH, MCPS, DCH, MBBS Professor & Head, Department of Community Medicine, College of Medicine Princess Nourah Bint Abdul Rahman University, Riyadh, (KSA) Kingdom of Saudi Arabia

Kashif Shafique

MBBS (Dow), MPH (Glasgow), PhD (Glasgow) Honorary Senior Clinical Lecturer (University of Glasgow) Associate Professor & Vice Dean, School of Public Health, Dow University of Health Sciences, Karachi, Pakistan.

Public Health and Community Medicine © All rights reserved. This book, or any part thereof, may not be used or reproduced in any manner without written permission from the author and publisher. The rights of manuscript are reserved with the author, whereas the rights of layout design, type setting and other technical aspects are reserved with the publisher, Time Publisher, Medical Division.

ISBN: 978-969-8261-56-6 Public Health and Community Medicine

First Edition

1979

Second Edition

1984

Third Edition

1993

Fourth Edition

1997

Fifth Edition

2000

Sixth Edition

2003

Seventh Edition

2006

Eight Edition

2016

Like in medicine, knowledge in public health is also constantly changing. As new information becomes available, changes in procedures, treatment, preventive measures and the use of epidemiology and statistics becomes necessary. The editors/contributors and the publisher have, as far as it is possible, taken care to ensure that the information given in the text is accurate and up to date. However, readers are strongly requested to confirm that the information given complies with standards of practice and latest legislation.

Published in Pakistan by TIME PUBLISHER, Medical Division, Urdu Bazar, Hashmi Trust Building, Karachi, Pakistan. Tel.: 92-21-2625539 Email: [email protected]

Price Rs. 1095.00 US$ 50.00

Foreword (Public Health and Community Medicine)

It is a great honour and pleasure for me to write a Foreword for the 8th edition of “Public Health and Community Medicine” a legendary book on the subject. The first edition of the book was the brainchild of Late Prof. Mohammad Ilyas (1915-2007), legendary pioneer, who dedicated and devoted his life in the field of Public Health Education in Pakistan Ever since its first edition in 1979, seven editions of the book have already been published. For more than 3 decades the book continues to enjoy the reputation of being not only the most popular manual on the subject, but also a great source of learning and reference for Undergraduates, Postgraduates, teachers and public health scientists in the country and abroad. The new edition has taken a while longer than expected, almost a decade, due to the sad demise of Prof. Mohammed Ilyas and subsequently Dr. Hansotia who took over the initial responsibility to provide guidance for the 8th edition. Public Health is a dynamic field and several changes have taken place in this arena in the last decade. The current edition of the book has taken into consideration and incorporated all changes taking place in the field, regionally and globally. This credit goes to Prof. Muhammad Irfanullah Siddiqui who has taken the responsibility of providing very able leadership to the 8th edition of the book It has been a great pleasure for me to be part of humble contributor in the current edition. I have no doubt in my mind that the new 8th edition of the book will be much more popular than its predecessor among all students, teachers and scientists in the field of Public Health.

Dr. Abdul Gaffar Billoo Sitara-e-Imtiaz Professor Emeritus, Department of Paediatrics & Child Health, Aga Khan University, Karachi.

Dedication This book is dedicated to the revered memories of:

Dr. K. S. Shah

Founder Dean, Institute of Hygiene and Preventive Medicine & Public Health, Lahore. Head, Department of Communicty Medicine, Fatima Jinnah College, Lahore.

Dr. Mehar F. Honsotia

Associate Professor, Head of Department, Community Medicine (DMC) Registrar, Dow University of Health Sciences, Karachi.

Ghulam Qadir Malik

Professor, Chairman, Department of Community Medicine, Nishtar Medical College, Multan. Professor, Chairman, Frontier Medical College, Abbottabad.

All those contributors who have left us.

Dr. M. A. Ansari

Professor, Head, Department of Community Mecicine, Dow Medical College (DMC) Karachi.

Dr. Mohammad Iliyas

Principal, Sindh Medical College (SMC) Dean, Faculty of Health Sciences, Baqai Medical University, Karachi

Iftikhar Ahmed Khan Professor, Head, Department of Community Medicine, Khyber Medical College, Peshawar. Professor & Head, Department of Community Health Sciences, Gandhara University Medical College, Peshawar.

Dr. Shahida Rasheed

Professor, Chairperson, Department of Health Sciences, Ziauddin University, Karachi.

N. A. Jafery

Professor of Pathology, Jinnah Post Graduate Medical Centre, Karachi. Vice Chancellor & Advisor, Ziauddin Medical University, Karachi.

Sponsors to 8th Edition

The preparation of this edition has been sponsored by the following leading personalities, who have been teachers in professional institutions for several decades. They are:● N.A. Jaferey Advisor, Ziauddin Medical University, Karachi. ● Gaffar Billo Professor & Head, Department of Pediatrics, Aga Khan University, Karachi. ● Shahida Rasheed Professor and Head, Department of Community Medicine, Ziauddin University, Karachi ● Syed Aley Hasan Zaidi Chairman, Department of Pathology & Vice Dean, Postgraduate Medical Institute, Baqai Medical University, Karachi. ● Inayat H. Thaver Professor & Former Dean, Baqai Medical University, Karachi. ● Lubna Baig Professor & Dean APNA Institute of Public Health, Jinnah Sindh Medical University, Karachi. ● Zubair Ahmed Professor & Chairman, Department of Community Medicine, Baqai Medical College, Karachi. ● Meher F. Hansotia Former Registrar, Dow University of Health Sciences, Karachi. ● Ata Muhammad Chandio Dean, Benazir Medical University, Nawabshah.

About the Former Editor-in-Chief

After six years of service in the Health Department of Mysore State, now known as Karnataka in South India, Dr. Iliyas migrated to Pakistan in November, 1947. While residing in India, he was trained in Public Health at the All India Institute of Hygiene & Public Health, as well as, the Institute of Tropical Medicine at Calcutta. On arrival in Pakistan his employer happened to be, his distinguished Professor of Public Health Administration in Calcutta. After a period of two years of his service as a Quarantine Officer at the Karachi Airport, Dr. Iliyas was deputed for MPH training at Harvard University, and on completion of this course of training, he gained experience in various sectors of Public Health in Pakistan. It was during the martial law period of Gen. Ayub, that, he was invited to set the Ministry of Health in order, since it was facing problems of maladministration, nepotism and favouritism, and, bureaucracy was not cooperating according to the expectation of the new government. Earlier he was also designated to a concurrent post of Professor of Hygiene (at Dow Medical College) as, it was known at that time. Holding this post, his method of teaching followed an integrated approach, conducted open book and MCQ examinations, not known in Pakistan at that time. In mid-fifties the functions now included in Primary Health Care were organized at a Basic Health Unit at Bizerta Lines. A Preventive Paediatric Unit was established at the JPMC with himself, a Resident Medical Officer of Paediatric Section Dr. Ms. Tahira Akbani and a Medico-social worker Ms. Khan became the staff members for teaching as well as health services, which inter alia covered immunization, health counselling, treatment of ailments and counselling on health promotion. Both the Basic Health Unit and the preventive paediatric units became teaching and demonstration centers for Dow Medical College which was the only college in Karachi at that time. WHO experts who visited Pakistan during that period paid rich tributes to his efforts and later sent a written communication offering him an assignment without even his application. The ministry however, did not spare him for this post. During the Ayub’s Martial Law regime, a proposal came up for the establishment of the College of Physicians and Surgeons and he was assigned the task of its first Secretary in addition to his teaching and administration. After four years of spade work under the guidance of General Burki, the Minister of Health, the college came into existence and attained the status of world renowned institution producing thousands of postgraduates in Medical Sciences, of international standing.

During the year 1963, the Government of Pakistan deputed him to the World Health Organization, EMRO, as a Public Health Administrator in Saudi Arabia, where he worked for four years and transferred to Western Pacific Region from where he retired during mid-seventy five. While in Korea, he succeeded in the establishment of a National Teacher Training Centre - the first center in the world at the national level, the components of this center were three, - A training unit, a research center and a production unit. During his eight years’ service in Korea, he became the recipient of several awards for meritorious services, the most distinguished one being the Civil Order of Merit, - The Favourite Flower of Korea by the President of that country. On his retirement from WHO, he was offered assignments from several countries, but he preferred to spend his remaining years of life in his home country. During 1977, he commenced working as an honorary professor of Community Medicine at Sindh Medical College where he became the Principal of that college. During his tenure of office at that college the President of the time sanctioned a gracious grant of nearly one and a half crore rupees for the college in appreciation of his honorary service as Principal without his asking. After a period of seven years, he relinquished this charge and joined Baqai Medical College in the private sector with support from Professor Zaki Hassan, Founder Principal of that college, he was able to establish a network of PHC centers catering for health, income-generation and community education. Professor Baqai and his wife, Professor Mrs. Zahida Baqai, have earned the distinction of being pioneers in implementing the inter-sectoral approach of primary health care as defined at the Alma Ata Conference of 1978 with a focus on poverty alleviation and primary education besides health care. During his assignment at that college, which became a medical university, he commenced a training course of MPH which other institutions have subsequently followed. He is no more with us physically but his work has made him immortal Muhammed Usman Dawood Gaba Publisher

Preface to the 7th Edition

I do not intend to write a long preface. I merely wish to invite the attention of the young generation to the emerging problems that pose a challenge to Public Health at the community level. These have been presented in this edition as well as in the 6th. Particular attention is drawn to the section on Disaster Control and Management written by Ghulam Qadir Malik of Nishter Medical College, Multan. Had the attention of the policy makers been drawn to its recommendation, pre-disaster management would have been in existence, which would have minimized the effects of devastation and crippling subsequent to the earthquake of 8th October 2005, in Azad Kashmir and Northern Areas. Likewise the Nuclear arms race in developing countries, if not prevented will face a calamity that may be far more severe than that of Hiroshima and Nagasaki bombing. When I was a student at Harvard School of Public Health, teachings of atomic energy commenced in the year 1950 and we were shown the Giegy Mullar Counter and other devices for radiation detection and diagrammatically shown the devastation, a large city will face, when an attack is made by an atomic bomb. This diagram is still in my mind and I have reproduced it in the chapter on Nuclear Medicine by R.A. Khan. The health personnel should also be prepared for possible relief work in the event of future natural disasters that may threaten human, animal and plant life due to climate changes, floods, earthquakes, scarcity of water, reduction in food sources due to crops failure beside environmental degradation, as a result of man’s interference in the natural ecosystem. The new dimensions added in this edition are Suicide, Obesity and Effective Treatment of Malaria. The last component has been reproduced with the kind permissions of W.H.O. from W.H.O. bulletin, January 2006. Dr. Mehtab Karim & Dr. A. Ghaffar Billo of Aga Khan Medical College, who have international fame have, through painstaking efforts updated the sections on Demography and Integrated Management of Childhood Illnesses respectively. Dr. Muhammad Irfanullah Siddiqui has revised the section on Health Information & Biostatistics and given a new dimension to its presentation making it understandable to all categories of Health Professions. Finally I find no words to thank for continued efforts of Mr. Muhammad Usman the publisher and his team namely Mr. Abbas Ali Khan and Professor Abdul Mobin Khan. Finally the painstaking efforts made by Registrar and In-charge Department of Community Medicine at Dow University of Health Sciences Dr. Meher F. Hansotia for cross checking omissions and adding new information, year after year is praiseworthy. I am of considered opinion that he richly deserves an academic award. A humble servant devoted to the cause of Community Medicine and a prayer for an up gradation of its low profile in Pakistan. Muhammad Iliyas Editor-in-Chief Karachi, August 2006

A word for Prof. Ilyas

I feel all that pain, while writing these lines, which is associated with loss of your most precious things. Prof Iliyas, who was one of the pioneer of this book, was a fatherly figure to me. During my ten years at Baqai University, I have learned a lot from him, first as a student, and then as colleague in the capacity of lecturer, Assistant professor and Associate professor. However I had most of the learning when I was promoted as Associate Dean. I do not have words, to write anything, for such a legendary figure and of course, there are no words to describe his great personality. I could never imagine, when I was taking him to Prof. Zakiuddin Oonwala, for a consultation on May 17, 2007, that he would be no more with us next day. He had a very kind personality and was always positive towards community issues. He had developed a model of integrated primary health care centers as a practical example of implementing the PHC strategies to achieve the health for all. I have found no such model in any other part of Pakistan and it was so successful and popular that I was invited by Oxford Brooks University, England in 2003 to deliver a lecture to the faculty and post graduate students on this PHC model, while serving as Dean Faculty, after the retirement of Prof. Iliyas. It was a hot day of June 2003, when I entered the office of Lt. General (retd.) Syed Azhar Ahmed, then Vice Chancellor of Baqai Medical University, to discuss some issues related to faculty and was surprised to know that VC has written a letter to Prof Iliyas requesting him, to inherit the responsibility of editing of community medicine book to me. I disagreed with him because I was of the opinion that this is such a huge task that I would not be able to do it, but he insisted that in the current scenario of public health you are the person, who have experience, motivation and commitment to do it. Later on at a meeting at his residence, Prof. Iliyas, gave me the reference of General Azhar’s letter and told me that he had already decided to share the responsibility of editing with me along with Dr. Mehr Hansotia even before the request of Lt. General (retd) Syed Azhar Ahmed. Dr. Mohamad Iilyas, served Dow Medical College, Karachi as Professor of Community Medicine from 1952 to 1963. He served at many important positions including the first Secretary of College of Physician and Surgeons Pakistan from 29th April 1963 to 31st January 1964. He died in Karachi at the age of 92. He also served the Ministry of Health Government of Pakistan, as Senior Medical Officer. He joined World Health Organization in 1964 as Advisor Health, Manpower Development and Community Medicine and served WHO for over eight years. Upon his return, he joined Sindh Medical College as Professor of Community Medicine in 1977 and Principal of the College in 1980. He served Sindh Medical College till 1984. Upon his retirement, he joined Baqai Institute of Health Sciences, (which later became Baqai Medical University) as Principal in 1990. He served Baqai Medical University as Professor and First Dean of Community Medicine. He initiated a program leading to Masters in Public Health in 1992. This program played a key role in development of public health personalities in the country. Most of the graduates of this institute are now serving at key position in administration, planning and research division of Ministry of Health, Pakistan as well as heads of the department of community medicine in medical schools in Pakistan and abroad. Almost all of the senior faculty in community medicine departments of Pakistan are his student.

Born in 1915 at Mysore, India, he did his MBBS from Mysore Medical College and DPH from Calcutta, India. He did his MPH from Harvard University, USA. He was awarded FCPS by the College of Physicians and Surgeons in 1987. He was also decorated with a Civil Award by the President of Korea. He breathed his last on 18th May, 2007 in Karachi. The best way to pay tribute to the greatest personalities is to keep their work alive. In this regard a meeting was held at the residence of Prof. Naeem Jaffery, Ex Vice Chancellor, Ziauddin University to complete, Prof. Iliyas’s, unfinished work for eighth edition. The member included were; Dr. Inayat Thaver, Dr. Shahida, Dr. Mehar Hansotia and Dr. Muhammad Irfanullah Siddiqui. Later on some more eminent personalities joined the arena, who had commitment with Prof Iliyas and his work, including Prof. A. Gaffar Billo, Prof. Aley H Zaidi, Prof. Lubna Baig, Prof. Rafiq Soomro, Prof. Farida Habib, Prof. Asifa Ghazi, Prof. Iqbal Akhtar, Prof. Farhat Jafry, Prof. Ata Mohammad Chandio, Dr. Ali Yawar and Dr. Kashif Shafique, and by their full effort, this edition is now in your hand. Unfortunately Dr. Mehar, who was a very active member of the team and right hand of Prof Iliyas, left us in 2011 and much of the work, he had done for the current edition, was lost. Rest of the team, along with new members, kept on working for the current edition and, with the grace of Allah SWT, were able to fulfill the promise made to Prof. Iliyas. We hope that this much awaited edition will serve as great tribute to his services. Muhammad Irfanullah Siddiqui March, 2016.

Acknowledgement

The editor wishes to acknowledge with thanks the assistance of Dr. Gaffar Billo, Dr. Aley Hasan Zaidi, Dr. Shahida Rasheed, Dr. Ghulam Qadir Malik, Dr. Rafique Somroo and Dr. Zubair for their devoted and untiring efforts in all the editions. Thanks to Dr. Shahida Rasheed and Dr. Kashif Shafique for reviewing and proof reading of all the composed chapters of this edition. I will be failing in my duty if I do not mention Dr. Mehr Hansotia (late), Dr. Farida Habib, and Dr. Asifa, Dr. Muhammad Saddique for the addition of some good and innovative material to the current edition. I am thankful to Dr. Inayat H. Thaver and Dr. Lubna Baig for their kind support in this edition as well as in all previous editions. In the end I wish to extend my gratitude to Professor Naeem Jaferey of Ziauddin University to take full interest in publication of eighth edition of this book of historical importance.

Preface to the 8th Edition

Overlooking the practice of recording the prefaces of all previous edition, we have ventured to present my thoughts on the eighth edition, Knowledge is expanding at a much higher rate than world had ever witnessed. To meet this need a book should be updated at least once in two years. Unfortunately this edition of the book took more than nine years to get itself updated because of many factors beyond the control of editors. We intend not to write a long preface, but an explanation of the need for meeting the health challenges of the current century, which the young generation, the future health providers, may face. After they have read it, we would invite them to take the material to those, who work for the communities who have been deprived of basic health services, not to speak of sophisticated diagnostic and treatment technologies, limited only to those whose financial resources are in abundance. If they find that we have helped them even the least bit in understanding the urgency needed for the access for health for all, - a goal enunciated at Alma Ata Conference in 1978, and, appreciating the efforts, both us and those who have spared their time for this work, we would claim that our humble attempt is justified. We (Dr. IH Thaver, Dr. Mehar Hansothia, Dr. Shahida Rasheed and Dr. Muhammad Irfanullah Siddiqui) under the patronage of Dr. Naeem Jafery, began to work for the revision and updating the information of the various sections, in the second half of 2008. Several meetings were held to discuss the improvement for the current edition. We decided to restructure the chapters sequences, addition of current public health issues as well as adding of objectives in the beginning of each chapter, so that, every student should know, what learning outcome is expected from him/her after each chapter. It was further decided to improve the index and add some more key words in order to ease the finding of a topic. It was also decided to remove redundant material and avoid duplication and contradicting information. The whole team, worked very hard day after day. Had it not been for their association we would not have succeeded in our efforts for the 8th edition of this book. Later Dr. Gaffar Billo, Dr. Lubna Baig, Dr. Aley Hasan Zaidi, Dr. Rafique Soomro, Dr. Farida Habib Khan, Dr. Kashif Shafique and Dr. Asifa joined hand to take the task to the end. Research is the stepping stone for development and goes a long way for progress. Dr. Shahida Rasheed has updated her chapter by adding, not only, the current modern tools of measurement and addressed issues of validity in research but described both quantitative and qualitative research as a mixed approach, in a logical sequence. Of all the health challenges of the current century the most serious one that health providers may have to face is one due to nuclear arms race. The devastation caused by nuclear bombing of Hiroshima and Nagasaki in Japan is before us. The chapter on Nuclear Medicine contains a brief description of this catastrophe presented by survivors who travelled from one country to another depicting photographic pictures of the devastation and the problems hospitals had to face. The main chapter on Nuclear Medicine has been written by Dr. R. A. Khan. Some topics which were more relevant to biostatistics were transferred from epidemiology to biostatistics and vice versa.

The chapter on helpful methods of Anthropology had a wide applause, and is of practical use by scientists in Pakistan. we owe our thanks to Prof. Denis Mull and his lady who presented her anthropological (Tradition) findings for staff and post graduate students in Islamabad some years ago. Chapter on health information narrates the concepts of biostatistics in a story like fashion and links all the topic in a logical and coherent way. Chapter on Demography was revised by Dr. Rukhsana Majeed and Dr. Farida to include the current demographic data of public health importance. A new chapter on health policy was added by Dr. Sabeena Jalal to sensitize the health care provider about the current health policy and its implication on health. Section of social science includes chapter on biomedical ethics, which was updated to meet the needs of undergraduate students and received great appreciation by the reader when made available at Researchgate. More scientists were invited to write on emerging health issues. A chapter by Ali Yawar Alam on public health problem solving paradigm is a good addition for understanding public health priorities and factors affecting it. Moreover monitoring and evaluation of public health program is also a good addition to the current edition. A new chapter of introduction by Dr. Farida Habib Khan has been added, she had summarized the section of definition and added qualities of seven star doctors and millennium development goals. Some old chapters like air and ventilation, light and lighting, housing, climate and environmental hazards have been merged as environmental factors in health. Chapter on nutrition has been revised by “Nida Javed and” Dr. Kashif Shafique. Chapter of community dental health has been updated by Dr. Abdul Haleem. Chapter of integrated management of childhood illness has been given a new shape by Prof. A. Gaffar Billo. Chapter on cancer control has been rewritten by Dr. Kashif Shafique, under the guidance of Prof. Naeem Jafrey. Prof. Asifa Ghazi has given new vision to the reproductive health section. She has made the task of students fairly easy by adding plates and photographs and added Islamic perspective in reproductive health issues. Prof. Aley Hassan Zaidi has revised all his chapters and updated the information. He has added a new chapter on mycology. “Importance of surveillance has been emphasized by Anand Joshi in his newly added chapter on surveillance. Nosheen Zehra and Shahida Rasheed have revised the chapter on health management and information system to add relevant examples to make it more practical. Dr Akhtar Ali has completely reshaped the chapter of Military hygiene to add new knowledge regarding common disease and factors. Dr. Meher has strengthened the concepts of leadership by adding evaluation of leadership. Chapters on school health services has been revised by Dr. Farah Ahmed to delete redundant material and added new material like role of private sector relevant in Pakistani context. Dr. Amin has revised his chapter on community mental health to add some more objectives in the changing world context. Dr. Iqbal Akhtar has updated his chapters on sports medicine and travel medicine by adding psychological issues related to injury in athletes and ergogenic aids, doping and its legal aspects. The chapter on travel medicine is one of the most updated chapters of this edition and includes, not only recent data but addresses the issues of Hajj and travel kit. Preventive cardiology written by Dr. Javed Usman in the current edition has been added as separate chapter and addresses the issues of hypertension in children as well as revised version of hypertension classification and cost effective preventive cardiology. Dr. Zahir Shah has updated the section of occupational lung disorders to include the much needed details of silicosis, coal worker’s pneumoconiosis and asbestosis. Prof. A. G. Billo has given a new look to the chapter of communicable diseases written by various authors by updating the information in the light of current world scenario. He has deleted the redundant material and added the information about the emerging diseases and their control. Dr. Ejaz Vohra and Dr. Kashif Shafique have completely revised the chapter on non-communicable diseases to include the concept of metabolic syndrome especially with reference to Pakistan. They not only, highlighted the risk factors for non-communicable disease but focused on diabetes mellitus as one of the major killer in the developing countries.” The untiring efforts of the publisher Mr. Muhammad Usman and his team namely Abbas Ali Khan Khattak and Mr. Muhammad Faisal, Professor Abdul Mobin Khan is highly commendable. Though we have taken care of updating the information but the knowledge is expanding at a very rapid rate. You are requested to point out the deficiency in the current issue so that it may be rectified in the next issue. A humble servant of Community Health Science Muhammad Irfanullah Siddiqui

Editor in Chief, Professor, Faculty of Medicine, Umm Al-Qura University (KSA), Makkah Mukarramah, Saudi Arabia.

L’envol

I praise and glorify Allah who has enabled me to complete the work which was inherited to me by Prof Iliyas. I have systematically and unceasingly laboured for the 8th edition of community medicine. I had not imagined human jealousy should pursue one who seeks no monetary gain and pretend to be an authority on the subject. I have been consoled by many near and distant readers who have appreciated my efforts. I thank them all, and feel that they and I are fellow riders on steed of research in a field that is unlimited in scope compared to the traditional belief in Pakistan on community medicine of any importance, such relationship is dearer in any joint enterprise. No less important is the untiring efforts of the publisher Mr. Usman, who has time and again brought the manuscript to me and Dr. Kashif Shafique for reviewing and proof reading of the various chapters and now ready to bring about the current edition for which a complete computerized index has been appended. And so I pray, gentle reader that providence may guide thee to become a seven star doctor / dentist / nurse or a health provider and I wish thee to pray for me to continue my efforts in meeting the challenges of community health in the 21st century.

Muhammad Irfanullah Siddiqui Karachi, March 2016

Contributors

1. Aamir Omair MBBS, MPH, MBA Coordinator Research Unit, Medical Education King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

9. Ali Yawar Alam MBBS(K.E), MS epidemiology ( U.K), MPH (Johns Hopkins, USA), CPHQ (USA) Director Project Management Office, Strategy Management Department, Ministry of Health, Saudi Arabia.

2. Abdul Gaffar Billoo Sitara-e-Imtiaz Professor Emeritus, Department of Paediatrics & Child Health, Aga Khan University, Karachi

10. Amin A. Gadit MBBS(Dow), MRCPsych(London), FRCP(Ireland), PH.D(England), BCPsych(London), D.P.M.(Ireland), D.C.P.(Ireland), MCPS(Pak), Professor of Psychiatry, Memorial University of Newfoundland, Canada

3. Abdul Haleem PhD (University of the Punjab), M.Sc. (London), B.D.S.(BZU) Assistant Professor, Department of Community Dentistry & Oral Epidemiology, Qassim University, Saudi Arabia 4. Abdul Sattar Tabani M.B., D.C.H., D.C.P., MFSEM(IRL) ASSOMICGP, ACOEM Specialist Registrar, Occupational Medicine, Royal College of Physicians, Ireland. 5. Afroze Ramzan MBBS, FCPS, Associate Professor, Institute of Child Health, Karachi. 6. Ahmed Nazir Chowdhry MBBS, M.A. (Harvard), Ph.D., Dip. Stat., Professor of Epidemiology and Vital and Health Statistics, Dean Institute of Hygiene and Public Health College, Govt. of Punjab (Retd.) 7. Akhter Qureshi MBBS (Pb.), DPH(Pb.), FRSH (London), MAPHA (USA), Advisor to the Ministry of Health, Consultant World Bank. 8. Ali Faisal Saleem MBBS, FCPS, MSc (Clinical Research), Fellowship in Paediatric Infectious Disease Director Paediatric Residency Program, Assistant Professor Department of Paediatrics & Child Health Aga Khan University, Karachi.

11. Arjumand Faisal MBBS (Karachi), MCPS, FCPS 12. Asif Aslam MBBS, MPH (Harvard) UNICEF Programme Officer, Karachi 13. Asifa Ghazi MBBS, FCPS(Gynae/Obs) Professor gynae/obs at Dow medical college & Civil Hospital Karachi, Dow University of Health Sciences, Karachi 14. Assad Ali Abro MBBS Formerly Provincial Operations Officer, Sindh. World Health Organization. 15. Aziz Ahmed Siddiqi M.Sc., Formerly Director, KANUPP Institute of Nuclear Power Engineering, Karachi 16. Bilqees Mujib Ph.D (Karachi), Professor of Parasitology. Baqai Medical University. Karachi 17. Burney M. I. MBBS, M.C. PATH. (London) FCPS, FRC Path (London), Specialist in Pathology Hilal-i-Imtiaz, Shousha Award (WHO), Global 500-Award for Environment (UNEP), Fellow Pakistan Academy of Science, Member WHO Technical Committies, USAAID Consultant, Formerly Director National Institute of Health, Islamabad.

18. Denis Mull M.D., M.P.H, Professor of Family Medicine, University of California, IRVINE. Recepient of 19 Grants Distinguished Consultant and Visiting Professor of Numerous Institution and Editor and eminent Writer of Several books and journals. 19. Farah Ahmad Assistant Professor Department of Community Health Sciences Ziauddin University, Karachi. 20. Farah Muhammad Asad Mansuri MBBS, MCPS, FCPS Professor Dept of Community & Family Medicine Taibah University Al Medinah Munawara Saudi Arabia 21. Farida Habib Khan FCPS, MPH, MCPS, DCH, MBBS Professor & Head, Department of Community Medicine, College of Medicine Princess Nourah Bint Abdul Rahman University, Riyadh, (KSA) Kingdom of Saudi Arabia 22. Fauzia Imtiaz BSc, MBBS, MSc, LLB, M.Phil, FCP(Path), PhD Professor of Biochemistry, Dow Medical College, Dow University of Health Sciences, Karachi 23. Gulam Murtaza MBBS, Director, Emergency Department, Govt. Hospital, Alkhobar, Saudi Arabia. 24. Hashim Ali Kazmi B.Sc. (Pb.), MBBS, DPH, M. Phil., Professor of Pathology, Baqai Medical College, Karachi Formerly Professor at Sindh & Dow Medical College, Karachi.

25. Ijaz H. Aqeel BDS(Pb), FDS(Edin), RCS(Edin), FCPS(Pak) 26. Inayat H. Thaver Phd (UK), MCH (London) Chief Executive, Mustashaar Social Development Advisors and Head of Department (Public Health) School of Public Health, Al-Shifa Trust Hospital, Islamabad 27. Iqbal Akhtar Khan MBBS, DTM (USA), FACTM (Australia), Ph.D. Independent Scholar Lahore (Pakistan) 28. Ismat Majid MBBS, FCPS, DCH, DRCOG, Physician and Associate Professor Department of School of Pediatrics, Jinnah Postgraduate Medical Centre, Karachi (Retd), Professor, Baqai Institute of Health Sciences (Rtd.) 29. Jafery N. A. MBBS, FCPS (Pak), Diplomate of American Board of Pathology, Professor of Pathology, Jinnah Postgraduate Medical Centre, Karachi (Retd), Co-Director, National Teacher Training Centre, College of Physicians & Surgeons, Karachi, Vice Chancellor, Ziauddin Medical University, Karachi. 30. Jawaid Usman MBBS, MD,MCPS, MPH(Australia) MRCGP (Int) Professor and Chairman Department of Family Medicine Ziauddin University 31. Jill Randell Nutrition Advisor to Government of Pakistan & USAID. 32. K. Zaki Hassan MBBS, FRCP, FCPS, DEAN, Jinnah Medical College, Karachi.

35. Lubna Baig Dean APPNA Institute of Public Health Jinnah Sindh Medical University Karachi 36. M. Riazul Haque Mohyuddin Brig. MBBS, DPH (Pb.), M.Sc (Med. Admn.), QUA, Associate Professor, Department of Community Medicine, Army Medical College, Rawalpindi 37. Mahmuda Mubasher Professor & Former Head of the Department of Community Medicine, Lahore Medical College, Lahore 38. Malik Gulam Qadir MBBS, M.D., DPH (Pb.), DCH, Professor and Head, Dept. of Community Medicine, Frontier Medical College, Abbottabad 39. Meher F. Hansotia MBBS, MCPS, DTM & H (London) Former Registrar, Dow University of Health Sciences, Karachi. Associate Professor & Incharge, Department of Community Medicine, Dow Medical College, Karachi. Provincial Co-ordinator Sindh Community Oriented Medical Education 40. Mehtab Karim Ph.D., Professor CHS and Head of Department of Reproductive Health, Aga Khan University Medical College 41. Memon Mohamed Saleh MBBS, M. Phil. Principal, Isra Medical College, Hyderabad, Sindh. 42. Mir Liaqat Ali Environment Consultant, Fellow of the American Board of Environment. 43. Mir Zahida Sultana MBBS (Pb.), DPH, MPH, Professor & Head, Department of Community Medicine, King Edward Medical College, Lahore. (Retd.), Consultant Child Survival Project GOP/ USAID, Islamabad.

33. Kashif Shafique MBBS (Dow), MPH (Glasgow), PhD (Glasgow) Honorary Senior Clinical Lecturer (University of Glasgow) Associate Professor & Vice Dean School of Public Health Dow University of Health Sciences Karachi, Pakistan.

44. Mohamed Afzal MBBS, MPH (Karachi), Associate Professor, Sir Syed Medical College for Girls, Karachi.

34. Kehkeshan Mufti MBBS, MPH, MCPS (Fam Med), Professor & Head, Department of Community Medicine, Layari Medical College, Shaheed Banazir Bhutto University, Karachi

46. Mohamed Iliyas B.Sc., MBBS (Mysore), DPH (Cal.), MPH (Harvard), FCPS, Former Dean, Faculty of Health Sciences, Baqai Medical University, Karachi.

45. Mohamed Ahmed Khan MD (USA), St. George University, New York.

47. Muhammad Irfanullah Siddiqui FCPS, M Phil, MPH, MCPS, MBBS Prof, Faculty of Medicine, Umm Al-Qura University Former Dean, Faculty of Health Management, Baqai Medical University 48. Muhammad Saddique Arain MBBS, FRCS(Edin) Head of department of Surgery, Baqai Medical University, Karachi 49. Naureen Mushtaq MBBS, MCPS, FCPS, Fellowship in Paediatric Oncology/ Hematology Assistant Professor Department of Paediatrics & Child Health Aga Khan University, Karachi. 50. Nida Jawed MSc. RDN. Consultant Dietitian Senior Lecturer Nutritional Sciences & BS-Nutrition Coordinator School of Public Health, Dow University of Health Sciences Vice President, Pakistan Nutrition & Dietetic Society 51. Nighat Nisar Professor Community Medicine Dow Medical College Dow University of Health Sciences Karachi, Pakistan 52. Sabeena Jalal MBBS, MSc (Harvard), PhD (Karachi University) Assistant Professor Community Health Sciences, Bahria University Medical and Dental College Karachi. Fulbright Scholar, Grand Challenges Grantee 53. Pathan Abdullah Jan MBBS, TDD, DTM & H (Eng.), DTCD (Wales), MRID (Japan), FCCP (America) 54. Paul Campbell Erwin MD. MPH. 55. Pfau Ruth M.D. Honorary Consultant to President of Pakistan and Director, Marie Adelaide Centre, Karachi. 56. Qureshi Fayyaz Ahmed MBBS, DPH (Pb.) Professor of Community Medicine, King Edward Medical College, Lahore. 57. R.A. Khan MBBS, MS (Radiation) University of Rochester, New York Professor of Nuclear Radiation, Ziauddin Medical University, Karachi Formerly Director, Atomic Energy Medical Centre, Jinnah Postgraduate Medical Centre Karachi.

58. Rafiq Ahmed Soomro HOD Community Medicine Liaquat National Medical College and Hospital Karachi and Ex-dean LUMHS Jamshoro. 59. Rana Ahsanul Haq M.Sc., Ph.D (Pb.), M.S. Columbia, Professor of Nutrition Institute of Hygiene and Preventive Medicine, Lahore (Retd.). 60. S. N. Bazmi Inam MBBS, MCPS, MPH (Harvard), FCPS Professor, Department of Family and Community Medicine, Qassim University, KSA. 61. Sadiqa Jafery MBBS, FRCOG, FCPS Professor of Gynaecology and obstetrics, Ziauddin Medical University, Karachi 62. Salahuddin Naseem MBBS (Pb.), Diplomat of the American Board of Internal Medicine, Consultant Physician, Liaquat National Hospital and Honorary Consultant Physician, Aga Khan University Hospital, Karachi. 63. Sameen Siddiqi MBBS., M.Sc (London), Asst. Professor, Academy of Health Sciences, Islamabad. 64. Saqib Shahab MBBS, MRCP, MPH, Environments Health & Occupational Medicine, Health Services Academy, Ministry of Health, Islamabad. 65. Shah K.S. MBBS (Pb), D.Sc. (Joh Hopkins), DPH (EdinO), DTM (Liverpool), Former Dean Institute of Hygiene and Preventive Medicine, Emeritus Professor of Bacteriology and Head of the Department of Community Medicine, Fatima Jinnah Medical College for Women, Lahore. 66. Shah Mohamed Zahir MBBS (Pesh.), DOH, MPH (Sydney), Professor and Head, Department of Community Medicine, Khyber Medical College, Peshawar.

67. Shaheena Manzoor MBBS, MSc (London), FCPS, Former Principal, Fatima Jinnah Medical College, Lahore. 68. Shahida Rasheed MBBS, MPH, MCPS, FCPS Chairperson Community Health Sciences Ziauddin Medical College, Karachi. 69. Shaukat Raza MBBS, FRCP, Professor of Paeds., King Edward Medical College, Lahore. 70. Sheikh Tanveer Ahmed MBBS, MPH Coordinator, Provincia Child Survival Training Unit, Department of Pediatrics, Civil Hospital, Karachi. 71. Shoukat Malik M.B.B.S., R.M.P. (Pak) FCPS., Nishtar Medical College, Multan. 72. Sohail Karim Hashmi MBBS, DPH, EX Secretary, Pakistan Medical & Dental Council, Islamabad. 73. Syed Aley Hasan Zaidi BSc, MBBS, MA (IR), M.Phil, FCPS, FRCP (Edin) PhD Life Fellow Royal Society Medicine (London) Former Chairman Dept. of Pathology Ex-Principal, Sindh Medical College & Hamdard College of Medicine & Dentistry Ex-Dean Faculty of Medicine, University of Karachi & Faculty of Medicine & Health Science Hamdard University, Karachi. Chairman, Department of Pathology & Vice Dean, Postgraduate Medical Institute, Baqai Medical University, Karachi. 74. Syed Azam Sher MBBS ( DOW ), M.Sc ( Env Sciences ) Specialist and Coordinator Public Health Department of Infectious Diseases and Vector Control Unit AlQassim Regional Health Directorate Buraida City, Saudi Arabia

75. Syed Mehmood Hasan MBBS, M.Phil (Path), FCP (Path), PhD. Chairman, Department of Pathology Jinnah Sindh Medical University Karachi 76. Syed Muhammad Hasan MBBS, MRCP (Dublin) Assistant Professor Medicine 77. Syeda Nosheen Zehra Assistant professor Department of Community Health Sciences, Ziauddin University, Karachi 78. Talat J. H. Rizvi MBBS (Pb), MPH (USA) Former Research Director, PMRC, Jinnah Postgraduate Medical Center, Karachi 79. Unaiza Niaz MD,DPM,FRCPsych Honorary Member The World Psychiatric Association, International Distinguish Fellow, American Psychiatric Association, Advisory Council Member, Women’s Mental Health, WPA, Advisory Board Member, International association of Women’s Mental Health, Vice President Eastern Mediterranean Region, & Board Member WFMH, 80. Zahid Naeem MBBS, FCPS Professor Department of Family and Community Medicine, Qassim University KSA