GOOD MORNING

1
 By

DR. MUMIN
CONCEPT OF DISEASE DEPARTMENT
OF PUBLIC
HEALTH
DENTISTRY

2
 CONTENTS

 INTRODUCTION

 CONCEPT OF CAUSATION

 THEORIES OF DISEASE CAUSATION

 EPIDEMOLOGICAL TRIAD

 MULTIFACTORIAL CAUSATION

 WEB OF CAUSATION

 NATURAL HISTORY OF DISEASE

 CONCLUSION

 REFERENCES
3
INTRODUCTION

4
 DISEASE - WEBSTER’S DEFINITION

“a condition in which body health is impaired,

a departure from a state of health,

an alteration of the human body interrupting the

performance of vital functions.”

5
 DISEASE - OXFORD DEFINITION

 “a condition of the body or some part or organ of

the body in which its functions are disrupted or
deranged.”

6
 DISEASE - ECOLOGICAL DEFINITION

 “a maladjustment of the human organism to the

environment.”

7
 DISEASE - SOCIOLOGICAL DEFINITION

 “a social phenomenon, occurring in all societies and

defined and fought in terms of a particular cultural
forces prevalent in the society.”

8
DISEASE - SIMPLEST DEFINITION

“OPPOSITE OF HEALTH”

9
 A VAST SPECTRUM OF DISEASE

 Subclinical --- severe

 Commence acutely --- some insidiously

 Carrier state

 More than one clinical manifestation

 More than one organism involved

 Short course --- prolonged course

10
 DISEASE / ILLNESS /SICKNESS

 Disease: a physiological / psychological dysfunction

 Illness: a subjective state of the person who feels

aware of not being well

 Sickness: is a state of social dysfunction, i.e., a role

that the individual assumes when ill (sickness role)

11
CONCEPT OF CAUSATION

12
 Ancient civilization in the east or the west applied its
rational to understand the concept of disease.

 Each civilization had its own interpretation of what

causes disease or the different factors that steer the
course of a disease.

13
 VARIOUS THEORIES OF DISEASE
CAUSATION
 The demonic theory
 The punitive theory
 Tridosha theory
 The theory of humors,
 Miasmatic theory of disease
 Germ theory of disease

14
 THE DEMONIC THEORY

 According to this theory, disease was produced by

demons, one or more evil spirits had fixed their
abode in the victim's body.

 The sick man was possessed of a devil.

 It was therefore logical to attempt to cure him by a

system of incantation and sorcery, something
calculated either to drive or coax the demon out.

15
 PUNITIVE THEORY

 According to this theory, the belief that one's

attitude toward the deity was responsible as a cause
of sickness. From a period centuries prior to the
christian era down to the present time, there have
been good people who have believed disease was a
punishment meted out by God for the sins of the
individual or the race.

16
 TRIDOSHA THEORY

 Tridosha theory is the foundation of Ayurvedic

concepts of health and disease.

 According to this theory, Disease or roga was

described as an imbalance of the three humors of
the body vata(outcome of the wind and earth
elements), pitta(manifestation of fire element), and
kapha(result of the water and earth elements).

17
 THE THEORY OF HUMORS

 Hippocrates (460-370, B. C.) instituted personal

treatment in the place of exorcising spirits,
sacrificing to unresponsive deities and other "absent
treatment.“

 The theoretical structure begun by Hippocrates, or at

least based upon his observations, was elaborated
and described by Galen and Ar-Razi (Rhazes) later
and is known as the theory of the four humours.
18
 It was conceived that there are in the normal body
four humours in a definite amount and proportion.
 Any excess of any one or any irregularity in their
distribution disturbed the fine adjustment of the
"going machine" and health was transformed to
sickness.
 These humours are blood, phlegm, yellow bile and
black bile.

19
 This gave the basis for the UNANI (Greco-Arabian)
system of medicine which gave a great importance
to temperament for the causation of disease which
may be correlated with the most of the metabolic
disorders.

 Avicenna (Ibn-e-sina) (1000CE) described

“Disease as an altered state and not an entity, and

morbid to that extent that it disturbs the normal
functions of the body”. 20
 MIASMATIC THEORY OF DISEASE

 The people, who believed in this, said that the air arising
from certain kinds of ground, especially low, swampy
areas, was a cause of disease.

 Certain places were thus given a very evil reputation,

because the ground was said to exude some invisible,
insensible vapor, some miasm, which produced disease.

 Such places were spoken of as unhealthy spots.

 Shakespeare found this miasmatic conception of
disease,
21
 SYDENHAAM’S TEACHINGS

 Sydenham (1644-1689), often- called the English

Hippocrates, first gave us the important thought that
there are different specific things which should be
held responsible for different diseases.

 Sydenham held that disease was the result of the

effort made- by the body to throw off, to expel these
materies morbi, the dead materials within it,' which
had made the trouble.'
22
 HAHNEMANN AND HOMOEOPATHY

 Homeopathy, in its essentials, is founded on the theory of

Hahnemann, who urged that disease is due to some
spiritual influence, that it consists of its symptoms taken
collectively, that it may be treated by the removal of
those symptoms and that this result is to be obtained by
introducing into the body of the sick person, in small
quantities, such drugs as have been found to produce the
identical symptoms in a well person.

23
 GERM THEORY OF DISEASE

Disease Agent Man Disease

 The concept of cause is generally referred to as one

to one relationship between causal agent and
disease.

 Only gives a one sided view of disease causation

24
 PROBLEMS OF GERM THEORY

 Not everyone exposed to tuberculosis develops tuberculosis

 Not everyone exposed to beta – hemolytic streptococci
develops acute rheumatic fever.
 Same exposure in undernourished or susceptible individual
may result in clinical disease
 Many other factors which influence both host and environment
for the disease to occur.

 These problems demanded a broader concept to disease

causation i.e., the concept of epidemiological triad
25
 EPIDEMIOLOGICAL TRIAD

Environment

Agent Host

 Was a broader concept of disease causation

 It has been used for many years

 It helped epidemiologists to focus on different classes of

factors, especially with regards to infectious diseases
26
 TRIANGLE OF EPIDEMIOLOGY

Environment

Time

Agent Host

 Based on communicable disease model

 Useful in showing the interaction and interdependence of
agent, host, environment, and time.

27
 Surroundings or conditions external to the human or
animal, that cause or allow the disease transmission

Environment

Time

Agent Host

Cause of the disease Organism (human/animal)

Incubation periods, life expectancy of the host/pathogen

and duration of the course of illness or condition
28
Infectious diseases:
Environment
• Bacteria
• Viruses
• Parasites Time
• Fungi
• Molds Agent Host
Non-infectious diseases:
• Chemicals from dietary foods
• Tobacco smoke
• Solvents
• Radiation or heat
• Nutritional deficiencies
• Other substances like poison
29
 Environment

Time Offers subsistence and lodging

for a pathogen.

Agent Host
Factors determining the disease:
• Level of immunity
• Genetic makeup
• Level of exposure
• State of health
• Overall fitness

30
 • Biological aspects
• Social aspects
• Cultural aspects
• Physical aspects

Environment

Time

Agent Host

31
 MULTIFACTORIAL CAUSATION

 Puttenkofer of Munich(1819-1901) was an early

proponent of this concept.

 The so called modern diseases of the civilization such as

lung cancer, coronary heart disease, chronic bronchitis,
mental illness, etc. could not be explained by germ
theory nor could be prevented by the traditional methods
of isolation, immunization or improvements in sanitation.

 These depend on multiple factors of causation.

32
ADVANCED MODEL OF TRIANGLE OF EPIDEMIOLOGY
33
 The advanced model of the triangle of epidemiology

includes all facets of the communicable disease model,

and to make it more relevant and useful with regard to

today’s diseases, conditions, disorders, defects, injuries

and deaths; it also reflects the causes of current

illnesses and conditions.

34
 The purpose of knowing the multiple factors of

disease is to quantify and arrange them in priority

sequence for modification or amelioration to

prevent or control disease.

 The multifactorial concept offers multiple

approaches for the prevention/control of disease.

35
 WEB OF CAUSATION

 Concept given by Macmahon and pugh

 Suited in the study of chronic diseases where the

disease agent is not known but is the outcome of
interaction of multiple factors.

 It considers all the predisposing factors of any type

and their complex interrelationship with each other.

36
 Sometimes removal or elimination of just only one
link or chain may be sufficient to control the disease,
provided that link is sufficiently important in the
pathogenic process.

 The relative importance of these factors may be

expressed in terms of “relative risk”

37
38
 NATURAL HISTORY OF DISEASE

 It is a key concept in epidemiology.

 It signifies the way disease evolves over time from

the earliest stage of its prepathogenesis phase to its
termination as recovery, disability or death, in the
absence of treatment or prevention.

 The natural history of disease is best established by

cohort studies .

39
 TWO PHASES OF NATURAL HISTORY OF
DISEASE

 1. Prepathogenesis phase

 2. Pathogenesis phase

40
41
 PREPATHOGENESIS PHASE

 This refers to the period preliminary to the onset of

disease in man. The disease agent has not yet
entered man, but the factors which favour its
interaction with the human host are already existing
in the environment.

42
 "man in the midst of disease" or

 "man exposed to the risk of disease".

 Potentially we are all in the prepathogenesis phase

of many diseases, both communicable and non -
communicable.

43
 The mere presence of agent, host and favorable
environmental factors in the prepathogenesis period
is not sufficient to start the disease in man. What is
required is an interaction of these three factors to
initiate the disease process in man.

44
 Environment

Agent Host

Epidemiologic concept of interactions of Agent, Host

and Environment

(Adapted from Health Services Reports, Vol, 87, page 672 45

 The agent, host and environment operating in
combination determine not only the onset of
disease which may range from a single case to
epidemics but also the distribution of disease in
the community.

46
 PATHOGENESIS PHASE

 The pathogenesis phase begins with the entry of the disease

"agent" in the susceptible human host.
 The further events in the pathogenesis phase are clear-cut in
infectious diseases, i.e., the disease agent multiplies and
induces tissue and physiological changes, the disease
progresses through a period of incubation and later through
early and late pathogenesis.
 The final outcome of the disease may be recovery, disability
or death. The pathogenesis phase may be modified by
intervention measures such as immunization and
chemotherapy. 47
 It is useful to remember at this stage that the host's
reaction to infection with a disease agent is not
predictable.

 That is, the infection may be clinical or sub-clinical:

typical or atypical or the host may become a carrier
with or without having developed clinical disease as
in the case of diphtheria and hepatitis B.

48
 In chronic diseases (e.g., coronary heart disease
hypertension, cancer), the early pathogenesis phase
is less dramatic.

 This phase in chronic diseases is referred to a

presymptomatic phase. During the presymptomatic
stags there is no manifest disease.

49
 The pathological changes are essentially below the level
of the "clinical horizon".

 The clinical stage begins when recognizable signs or

symptom appear.

 By the time signs and symptoms appear, the disease

phase is already well advanced into the late
pathogenesis phase.

 In many chronic diseases, the agent-host environmental

interactions are not yet well understood.
50
 AGENT FACTORS

 The disease agent is defined as

“a substance living or non-living, or a force, tangible or
intangible, the excessive presence or relative lack of
which may initiate or perpetuate a disease process.”

 A disease may have a single agent, a number of

independent alternative agents or a complex of two
or more factors whose combined presence is
essential for the development of the disease 51
Agent factors Infectivity

Biological agents
Pathogenicity
(viruses, fungi, bacteria, etc.)

Virulence

Proteins, fats,
Nutrient agents carbohydrates, vitamins,
minerals and water

excessive heat, cold,

Physical agents humidity, pressure.
radiation, electricity, sound,
52
 Chemical agents
Produced in the body as a result of
derangement of function, e.g., urea
(ureamia), serum bilirubin (jaundice),
Agent factors
Endogenous ketones (ketosis), uric acid (gout),
calcium carbonate (kidney stones)

Exogenous
Agents arising outside of human host,
e.g. allergens, metals, fumes, dust, gases,
insecticides, etc.
These may be acquired by inhalation,
ingestion or inoculation

Mechanical chronic friction and other mechanical force:

agents may result in crushing, tearing, sprains,53
dislocations and ever death.
 Chemical factors: e.g.,
hormones (insulin
Agent factors oestrogens, enzymes)

Nutrient factors

Lack of structure: e.g..

Absence or insufficiency thymus
or excess of a factor
necessary to health Lack of part of
structure: eg. cardiac
defects

Chromosomal factors:
eg, syndromes

Immunological factors
54
Agent factors Poverty

Smoking

Abuse of drugs

Social factors Alcohol

Unhealthy lifestyles

Social isolation

Maternal deprivation 55
 HOST FACTORS (INTRINSIC)

 In epidemiological terms

AGENT
HOST
SEED

SOIL

56
 Demographic Age, sex, ethnicity
characteristics
Host factors
Biochemical levels of blood

Blood groups and enzymes

Biological Cellular constituents of blood

characteristics

Immunological factors

Physiological functions
57
 Socioeconomic status
Host factors
Education

Occupation
Social and economic
characteristics
Stress

Marital status

housing

58
 Personality traits
Host factors
Living habits

Nutrition

Lifestyle factors
Physical exercise

Use of alcohol, drugs and

smoking

Behavioral patterns
59
 ENVIRONMENTAL FACTORS (EXTRINSIC)

 The external or macro-environment is defined as:

“all that which is external to the individual human

host, living and non-living, and with which he is in
constant interaction.”

60
Environmental factors

Physical Biological Psychosocial

environment environment environment

61
 PHYSICAL ENVIRONMENT

 Non living things and physical factors ( air, water,

soil, housing, climate, geography, heat, noise, debris,
radiation, etc.) with which man is in constant
interaction.

62
 The increasing use of electrical and electronic
devices, including the rapid growth of
telecommunication system (e.g., satellite systems),
radio-broadcasting, television transmitters and radar
installations have increased the possibility of human
exposure to electromagnetic energy.

 Man is living today in a highly complicated

environment which is getting more complicated as
man is becoming more ingenious. If these trends
continue, it is feared that the very "quality of life" we
cherish may soon be in danger.
63
 BIOLOGICAL ENVIRONMENT

 The universe of living things which surrounds man,

including man himself.

 The living things are the viruses and other microbial

agents, insects, rodents, animals and plants.

 These are constantly working for their survival, and

in this process, some of them act as disease-
producing agents, reservoirs of infection,
intermediate hosts and vectors of disease. 64
 Between the members of the ecological system (which
includes man) there is constant adjustment and
readjustment towards a harmonious inter-relationship,
to achieve a state of peaceful co-existence.

 When for any reason, this harmonious relationship is

disturbed, ill health results.

 In the area of biological environment also, preventive

medicine has been highly successful in protecting the
health of the individual and of the community.

65
 PSYCHOSOCIAL ENVIRONMENT

 Psychosocial factors which are defined as "those

factors affecting personal health, health care and
community well-being that stem from the
psychosocial make-up of individuals and the
structure and functions of social groups"

66
 They include cultural values, customs, habits, beliefs,
attitudes, morals, religion, education, lifestyles,
community life, health services, social and political
organization.

67
 PSYCHOSOCIAL FACTORS
poverty, urbanization, migration and exposure to stressful
situations

anxiety, depression, anger, frustration,

endocrine, autonomic and motor

systems

structural changes in various

bodily organs.

duodenal ulcer, bronchial asthma, hypertension, coronary

heart disease, mental disorders and socially deviant
behaviour (e.g., suicide, crime, violence, drug abuse). 68
 Man today is viewed as an "agent" of his own
diseases.
For example:
LUNG CANCER
Medical Cause Carcinogenic Substance

Psychological Cause Smoking- Behavior

69
 From a psychosocial point of view, disease may be
viewed as a maladjustment of the human organism
to his psychosocial environment resulting from
misperception, misinterpretation and misbehaviour.

 The epidemiologists today are as much concerned

with psychosocial environment as with physical or
biological environment, in search for aetiological
causes of disease.

70
 RISK FACTORS

 For many diseases, the disease "agent" is still

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

71
The term risk factor is defined as;

 an attribute or exposure that is significantly

associated with the development of a disease;

 a determinant that can be modified by intervention,

thereby reducing the possibility of occurrence of
disease or other specified outcomes;

72
 The presence of a risk factor does not imply that the
disease will occur, and in its absence, the disease
will not occur.

 The important thing about risk factors is that they

are observable or identifiable prior to the event they
predict.

73
 Risk factors

Additive Synergistic Causative

Smoking +
occupational Lung cancer
exposure Smoking +
hypertention
Bladder + high blood
cancer cholesterol

74
 Smoking

Hypertention

Elevated serum
Modifiable
cholestorol
Risk factors

Physical activity

obesity

Age

Sex

Un-modifiable Race

Family history

Genetic factors 75
 SPECTRUM OF DISEASE

 It is a graphic representation of variations in the

manifestations of disease.

76
 ICEBERG OF DISEASE

 A concept closely related to the spectrum of disease

is the concept of the iceberg phenomenon of
disease.

 According to this concept, disease in a community

may be compared with an iceberg .

 The floating tip of the iceberg represents what the

physician sees in the community, i.e., clinical cases.

77
ICEBERG OF DISEASE

78
 The vast submerged portion of the iceberg represents the
hidden mass of disease, i.e., latent, inapparent.
presymptomatic and undiagnosed cases and carriers in the
community.

 The "waterline" represents the demarcation between apparent

and inapparent disease.

79
 CONCLUSION

 The concept of disease is as old as mankind itself.

Man has always tried to understand natural
phenomena and attempted to give his own
explanation to it.

80
 With the advent of growing intellect and latest
technological advancement this concept has greatly
been improved upon but still there is a sea of
diseases and their submerged concepts which needs
to be unveiled so as to find better ways of treatment.

 A wise scholar has rightly said, “The Almighty has

kept a remedy for every disease, which is known by
some and ignored by others”.
81
 REFERENCES

 K. Park. Textbook of Preventive and Social Medicine:

23 rd edition. Pg. 32-39

 Surendra k. and Prasad J. CONCEPT OF ETIOLOGY IN

AYURVEDA AND WESTERN MEDICINE. International
Ayurvedic Medical Journal

 The Canon of Medicine, By: Avicenna, Mazhar.H

Sha.TPk, Idarah Kitab Al Shifa,New Delhi, India

82
 REFERENCES

 Measures of Morbidity in a Community Disease

Spectrum. Available from:
http://www.crcpress.com/product/isbn/978143988
4140

 L. W. Feezer. Theories concerning the causation of

disease. Causation of disease. The american journal
of public health. Pg. 908-12

83
THANK-YOU

84