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SECTION A: Fundamental Concepts of Community Medicine, Public Health & History

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1. Define Community Medicine

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2. Define Preventive Medicine

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3. Define Social Medicine

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4. Define Public Health

• Sanitation of the environment
• Control of communicable diseases
• Education of individuals in personal hygiene
• Organisation of medical and nursing services for early diagnosis and preventive treatment
• Development of social machinery to ensure a standard of living adequate for the maintenance of health

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5. Functions of Public Health

1. Assessment of community health needs
2. Policy development (formulating health policies)
3. Assurance (ensuring services are available)
4. Disease surveillance and investigation
5. Health promotion and education
6. Enforcement of health-related laws
7. Environmental health protection
8. Research into health problems

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6. Differentiate Preventive Medicine vs Public Health

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7. History of Public Health

• Ancient period: Sanitation in Mohenjo-daro; Ayurveda emphasised hygiene
• Middle Ages: Plague pandemic; quarantine introduced (Venice, 1374)
• 17th-18th century: John Graunt (vital statistics), Ramazzini (occupational disease)
• 19th century (Era of Sanitary Reform): Edwin Chadwick (1842 Report), John Snow (cholera, Broad Street pump, 1854), Pasteur and Koch (germ theory), Joseph Lister (antiseptics)
• 20th century: Antibiotics, vaccination, WHO (1948), Alma Ata Declaration (1978), Health for All
• Modern era: SDGs, Universal Health Coverage

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8. Evolution of Public Health Globally

1. Pre-scientific era - miasma theory, sanitation
2. Era of bacteriology - Pasteur, Koch, germ theory (late 19th century)
3. Era of health promotion - lifestyle, social determinants
4. Era of social engineering - WHO, HFA 2000, PHC
5. Era of new public health - modern epidemiology, evidence-based public health, SDGs

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9. Evolution of Public Health in India

• Ancient India: Ayurveda (Charaka, Sushruta), emphasis on personal hygiene, food, seasons
• British period (pre-independence): Plague commissions, Bhore Committee (1946)
• Post-independence: Five Year Plans, National Health Policy (1983, 2002, 2017), NRHM (2005), NHM (2013)
• Current: Ayushman Bharat, PM-JAY, Health and Wellness Centres

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SECTION B: Concepts of Health, Disease Causation & Prevention

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10. Concept of Health (14 Definitions)

1. Physical - proper functioning of body systems
2. Mental - psychological well-being, ability to cope
3. Social - ability to interact and fulfil social roles
4. Spiritual - sense of purpose and meaning in life (added later)
5. Emotional - ability to express feelings appropriately
6. Vocational - ability to work productively

• Biomedical model: Health = absence of disease
• Ecological model: Balance between host, agent, environment
• Social model: Health as ability to perform social roles
• Holistic model: Integration of all dimensions
• WHO (1984): "Extent to which an individual or group is able to realize aspirations, satisfy needs, and change or cope with the environment"

• Positive health: optimal level of functioning
• Better health: above average health
• Freedom from sickness: absence of illness
• Mild illness: minor self-limiting conditions
• Severe illness: needs professional intervention
• Death: ultimate end

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11. History of Health (Discuss the History of the Concept of Health)

• Early concept: health = absence of disease (biomedical model)
• 1948: WHO broadened to include mental + social well-being
• 1977: Health for All by 2000 (WHA)
• 1978: Alma Ata Declaration - Primary Health Care as key
• 1986: Ottawa Charter - health as a resource for living
• 1984: WHO updated definition to include ability to realize aspirations

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12. Biomedical, Ecological, Psychological and Spiritual Dimensions of Holistic Health

• Biomedical: Focuses on pathology, biochemistry, microbiology; disease = malfunction of organ/system
• Ecological: Health as dynamic equilibrium between man and environment; triad of host-agent-environment
• Psychological: Emphasises mental health, coping mechanisms, stress, personality
• Spiritual: Inner peace, meaning, purpose, moral values
• Holistic model (Park): Combines all dimensions; views man as a whole being, not just sum of parts

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13. Define Health as per WHO

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14. Disease Causation - Theories (Primitive and Middle Ages)

• Disease attributed to supernatural forces, evil spirits, gods' punishment
• Treatment = prayer, exorcism, sacrifices, shamans

• Miasma theory: disease caused by "bad air" from rotting matter
• Humoral theory (Hippocrates): imbalance of 4 humours (blood, phlegm, yellow bile, black bile)
• Astral theory: influence of stars and planets

• Fracastoro (1546): "contagion" concept - seeds of disease passed person to person
• Led eventually to germ theory

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15. Germ Theory of Disease

1. The organism must be found in all cases of the disease
2. It must be isolated from the diseased individual and grown in pure culture
3. The pure culture must reproduce the disease when inoculated into a susceptible animal
4. The organism must be re-isolated from the experimental animal and shown to be identical to the original

• Healthy carriers (e.g., V. cholerae, M. tuberculosis)
• Some diseases are caused by multiple agents
• Does not explain social and environmental factors
• Viral diseases: some cannot be grown in pure culture

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16. Biomedical Model of Health

• Health = absence of disease
• Disease = malfunction of biological mechanisms
• Treatment = correct the malfunction (drugs, surgery)
• Ignores social, psychological, environmental factors
• Basis for modern Western medicine

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17. Characteristics of Agent, Host, and Environmental Factors (Epidemiological Triad)

Agent Factors

• Biological: bacteria, viruses, fungi, parasites
• Physical: heat, cold, radiation, trauma
• Chemical: poisons, allergens, carcinogens
• Nutritional: deficiency or excess of nutrients
• Psychological: stress, anxiety

Host Factors

• Intrinsic: age, sex, genetics, race, nutritional status
• Acquired: immunity (natural/artificial), past illness
• Behavioral: lifestyle, habits (smoking, diet, exercise), occupation

Environmental Factors

• Physical: climate, geography, season
• Biological: vectors, reservoirs, animal hosts
• Social: poverty, education, housing, sanitation, culture

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18. Web of Causation (MacMahon & Pugh, 1960)

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19. Multifactorial Aetiology of Disease & "BEINGS" Model

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20. Predisposing, Enabling, Precipitating, Reinforcing and Risk Factors

• Predisposing factors: Increase susceptibility before exposure (age, sex, prior illness, genetics) - e.g., elderly are predisposed to pneumonia
• Enabling factors: Facilitate disease or recovery (low income enables malnutrition; good housing enables recovery)
• Precipitating factors: Directly trigger disease onset (exposure to causative agent, cold weather triggering asthma)
• Reinforcing factors: Perpetuate or worsen disease once started (repeated exposure, poor nutrition during illness)
• Risk factors: Attributes/exposures that increase the probability of disease (smoking for lung cancer, hypertension for stroke)

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21. Natural History of Disease

1. Stage of susceptibility - no disease yet; host, agent, environment interacting
2. Stage of presymptomatic disease - pathological changes begun; no symptoms (subclinical)
3. Stage of clinical disease - signs and symptoms appear
4. Stage of disability - residual impairment
5. Stage of recovery/death

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22. Natural History & Evolution of Disease

• Subclinical (inapparent) → Mild → Moderate → Severe → Fatal
• Inapparent infections are important epidemiologically (source of spread)

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SECTION C: Nutrition for Community

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23. Define Nutrition, Food, Diet and Nutrients

• Nutrition: The science of food and its relationship to health; the process by which organisms obtain and utilise food
• Food: Any substance, whether processed, semi-processed or raw, which is intended for human consumption and includes drink and any substance used in preparation
• Diet: The total amount and variety of food/drink regularly consumed by a person
• Nutrients: Chemical substances in food that perform physiological functions - carbohydrates, proteins, fats, vitamins, minerals, water

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24. Classify Nutrients

• Carbohydrates (4 kcal/g)
• Proteins (4 kcal/g)
• Fats (9 kcal/g)

• Vitamins (fat-soluble: A, D, E, K; water-soluble: B complex, C)
• Minerals (calcium, iron, zinc, iodine, fluoride, etc.)

• Water
• Dietary fibre (roughage)

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25. Functions of Food

1. Energy supply - carbohydrates and fats
2. Body building - proteins, minerals
3. Regulatory - vitamins, minerals, water
4. Protective - antioxidants, vitamins
5. Social functions - pleasure, cultural bonding
6. Psychological - comfort, satisfaction

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26. Significance of Nutrition for Individuals and Community

• Adequate nutrition is essential for growth, development and productivity
• Malnutrition (under or over) increases morbidity and mortality
• Community nutrition affects economic productivity, educational performance, national development
• Maternal nutrition affects birth outcomes
• Poor nutrition weakens immunity, increases susceptibility to infections

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27. Classify Food by Origin, Chemical Composition, Major Function and Nutritive Value

1. Energy foods (cereals, sugars, fats/oils)
2. Body-building foods (milk, meat, eggs, pulses)
3. Protective foods (fruits, vegetables, animal foods rich in vitamins)

1. Cereals, millets, pulses
2. Vegetables and fruits
3. Milk and milk products
4. Meat, fish, poultry, eggs
5. Oils and fats, nuts and oilseeds

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28. Common Sources of Nutrients

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29. Nutritional Requirements by Age and Sex

• Requirements vary by: age, sex, physiological state (pregnancy, lactation), activity level
• Reference Indian man: 60 kg, moderately active; requirement ~2320 kcal/day (ICMR)
• Reference Indian woman: 55 kg, moderately active; ~1900 kcal/day
• Infants: Higher protein per kg body weight
• Adolescents: Increased requirements due to growth spurt
• Pregnant women: +350 kcal/day (2nd & 3rd trimester); extra protein and iron
• Lactating women: +600 kcal/day

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30. Recommended Dietary Allowance (RDA) and Estimated Average Requirement (EAR)

• RDA: Level of intake sufficient to meet the nutrient needs of nearly all (97-98%) healthy individuals in a group. RDA = EAR + 2 SD
• EAR: Intake level estimated to meet the requirement of 50% of healthy individuals in a group
• RDA > EAR always
• Set by ICMR for India; by NAS/IoM for USA
• Used for planning diets, evaluating food supplies, nutrition labelling

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31. Reference Man and Reference Woman

• Age: 20-39 years
• Body weight: 60 kg
• Occupational activity: Moderate (8 hours work, 8 hours light activity, 8 hours rest)
• Energy requirement: 2320 kcal/day

• Age: 20-39 years
• Body weight: 55 kg
• Moderate activity
• Energy requirement: 1900 kcal/day (not pregnant or lactating)

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32. Dietary Fibre - Classification and Functions

1. Soluble fibre: pectin, guar gum, oat bran - lowers cholesterol, slows glucose absorption
2. Insoluble fibre: cellulose, hemicellulose, lignin - increases stool bulk, prevents constipation

• Prevents constipation
• Reduces risk of colorectal cancer
• Lowers serum cholesterol (soluble fibre)
• Controls blood glucose (reduces glycaemic index)
• Helps weight control (satiety)
• Reduces risk of diverticular disease

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33. Vitamins - Sources, Functions, Deficiency Signs and Prevention

Vitamin A (Retinol)

• Sources: Liver, egg yolk, milk, yellow/orange vegetables (beta-carotene)
• Function: Vision (rhodopsin synthesis), epithelial integrity, immunity, growth
• Deficiency: Night blindness, Bitot's spots, xerophthalmia, keratomalacia, increased infection susceptibility
• Prevention: Vitamin A supplementation (NPCB), dietary diversification, fortification (POSHAN Abhiyaan)
• RDA: 600 mcg/day (adult)

Thiamine (Vitamin B1)

• Sources: Cereals (outer layer), pulses, nuts, pork
• Function: Carbohydrate metabolism (coenzyme in oxidative decarboxylation), nerve function
• Deficiency: Beriberi (wet - cardiac; dry - neurological; infantile - fatal)
• Prevention: parboiling rice, dietary diversification

Riboflavin (Vitamin B2)

• Sources: Milk, liver, eggs, green leafy vegetables
• Function: Electron transport (FAD, FMN); cellular respiration
• Deficiency: Ariboflavinosis - angular stomatitis, cheilosis, glossitis, corneal vascularisation, scrotal/vulval dermatitis
• Prevention: Regular intake of milk and green vegetables

Niacin (Vitamin B3)

• Sources: Groundnuts, whole cereals, meat, fish; synthesised from tryptophan
• Function: NAD, NADP coenzymes; energy metabolism
• Deficiency: Pellagra - "4 Ds": Dermatitis, Diarrhoea, Dementia, (Death)
• Casal's necklace (dermatitis on neck)
• Prevention: Dietary diversification; avoid exclusive maize diet

Pyridoxine (Vitamin B6)

• Sources: Meat, fish, potatoes, bananas, cereals
• Function: Amino acid metabolism, neurotransmitter synthesis
• Deficiency: Peripheral neuropathy, dermatitis, stomatitis (rare alone; often with INH use)

Folic Acid (Vitamin B9)

• Sources: Green leafy vegetables, liver, legumes
• Function: DNA synthesis, cell division, amino acid metabolism
• Deficiency: Megaloblastic anaemia, neural tube defects (NTDs) in pregnancy
• Prevention: 400 mcg/day periconceptional supplementation prevents NTDs

Vitamin B12 (Cyanocobalamin)

• Sources: Animal foods only (meat, fish, eggs, dairy); deficiency common in strict vegetarians
• Function: DNA synthesis, myelin synthesis, folate metabolism
• Deficiency: Megaloblastic anaemia, subacute combined degeneration of spinal cord, glossitis

Vitamin C (Ascorbic Acid)

• Sources: Amla (highest), guava, citrus fruits, tomato
• Function: Collagen synthesis, antioxidant, iron absorption, wound healing
• Deficiency: Scurvy - perifollicular haemorrhages, bleeding gums, corkscrew hairs, poor wound healing, Fraenkel's line (bone changes), Pelkan's spur
• Prevention: Fresh fruits and vegetables in diet

Vitamin D (Calciferol)

• Sources: Sunlight (UV-B, main source), fish liver oils, egg yolk, fortified milk
• Function: Calcium and phosphorus absorption and metabolism; bone mineralisation
• Deficiency: Rickets (children) - craniotabes, Harrison's sulcus, rosary, bowing of legs; Osteomalacia (adults) - bone pain, fractures
• Prevention: Sun exposure, dietary sources, supplementation

Vitamin E (Tocopherol)

• Sources: Vegetable oils, wheat germ, nuts
• Function: Antioxidant (protects cell membranes from oxidative damage), prevents haemolytic anaemia in premature infants
• Deficiency: Haemolytic anaemia in premature infants; peripheral neuropathy (rare)

Vitamin K

• Sources: Green leafy vegetables; also synthesised by gut bacteria
• Function: Coagulation factors (II, VII, IX, X) synthesis; bone metabolism
• Deficiency: Bleeding tendency; haemorrhagic disease of newborn
• Prevention: Vitamin K injection at birth

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34. Minerals

Calcium

• Sources: Milk and dairy (best), small fish, ragi, sesame
• RDA: 600 mg/day adults; 1200 mg pregnancy/lactation
• Functions: Bone and teeth formation, muscle contraction, nerve transmission, coagulation
• Deficiency: Rickets, osteoporosis, osteomalacia, hypocalcaemic tetany

Iron

• Sources: Haem iron (meat, liver, fish - better absorbed); non-haem (cereals, leafy vegetables, jaggery)
• RDA: 17 mg/day men; 21 mg/day women (ICMR)
• Functions: Haemoglobin synthesis, myoglobin, enzyme cofactor
• Deficiency: Iron deficiency anaemia - pallor, fatigue, koilonychia, glossitis, angular stomatitis
• Toxicity: Haemochromatosis

Iodine

• Sources: Iodised salt (primary intervention), seafood, dairy
• RDA: 150 mcg/day adults; 220 mcg pregnancy
• Functions: Thyroid hormone synthesis (T3, T4)
• Deficiency: Iodine Deficiency Disorders (IDD) - goitre, cretinism, hypothyroidism, stillbirths
• Control: Universal Salt Iodisation (USI)

Fluoride

• Sources: Fluoridated water (0.5-0.8 ppm), tea, seafood
• Functions: Prevents dental caries; bone mineralisation
• Deficiency (<0.5 ppm): Dental caries
• Excess (>1.5 ppm): Dental fluorosis; >3 ppm: skeletal fluorosis (endemic fluorosis in parts of India - Rajasthan, AP, Punjab)

Zinc

• Sources: Meat, shellfish, legumes, nuts
• Functions: Enzyme cofactor (>300 enzymes), immunity, wound healing, growth
• Deficiency: Growth retardation, hypogonadism, skin lesions, poor wound healing, impaired immunity, ageusia

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35. Describe the Epidemiology of Malnutrition (PEM, Vitamin A deficiency, IDD, Fluorosis)

PEM (Protein Energy Malnutrition)

• Most common nutritional problem in developing countries
• Kwashiorkor: Protein deficiency with adequate calories; oedema, skin changes, fatty liver, moon face, flaky paint dermatitis
• Marasmus: Severe calorie + protein deficiency; wasting, growth failure, alert face, no oedema
• Marasmic-Kwashiorkor: Mixed form
• Global burden: 45% of deaths under 5 are linked to undernutrition

Vitamin A Deficiency

• Leading cause of preventable childhood blindness
• India: ~0.34% children have Bitot's spots
• 2-6 year age group most vulnerable
• Prevention: NPCB supplementation (200,000 IU every 6 months for 1-5 years)

Iodine Deficiency Disorders (IDD)

• 200 million Indians at risk; goitre belt: sub-Himalayan regions
• Universal Salt Iodisation mandated in India

Fluorosis

• Endemic in 20 states of India; ~60 million affected
• Sources: Groundwater with high fluoride
• Types: dental, skeletal, non-skeletal

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36. Types of Malnutrition

1. Undernutrition: Insufficient intake of calories/nutrients
   • PEM, micronutrient deficiencies
2. Overnutrition: Excess intake
   • Obesity, hypervitaminosis, toxicity
3. Specific deficiencies: Vitamin A, iodine, iron, zinc
4. Imbalance: Improper ratio of nutrients
5. Double burden of malnutrition: Coexistence of undernutrition and overnutrition in same population/household (India faces this)

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37. Methods to Measure Malnutrition

1. Anthropometric methods:
   • Weight for age (underweight)
   • Height/length for age (stunting)
   • Weight for height (wasting)
   • MUAC (mid-upper arm circumference) - <12.5 cm = SAM
   • BMI (body mass index) = Weight (kg)/Height (m)²
   • Skinfold thickness (triceps, subscapular) - measures body fat
   • Head circumference (brain growth in infants)
2. Biochemical methods: Serum albumin, haemoglobin, serum retinol, serum ferritin, urinary iodine
3. Clinical methods: Signs of deficiency (Bitot's spots, oedema, pallor, wasting, skin changes)
4. Dietary methods: 24-hour recall, food frequency questionnaire, dietary history

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38. Classify and Interpret Nutritional Status of Infants, Children & Adolescents (Anthropometric)

Weight for Age (Underweight) - WHO Z-scores:

• Normal: > -2 SD
• Moderate undernutrition: -2 to -3 SD
• Severe undernutrition: < -3 SD

Height for Age (Stunting):

• Normal: > -2 SD
• Moderate stunting: -2 to -3 SD
• Severe stunting: < -3 SD

Weight for Height (Wasting - acute malnutrition):

• Normal: > -2 SD
• Moderate wasting: -2 to -3 SD
• Severe wasting: < -3 SD

• Grade I: 75-90% of expected (mild)
• Grade II: 60-75% (moderate)
• Grade III: <60% (severe)

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39. Stunting, Wasting and Underweight

• Stunting: Height for age < -2 SD; reflects chronic malnutrition; long-term growth failure
• Wasting: Weight for height < -2 SD; reflects acute malnutrition; recent weight loss
• Underweight: Weight for age < -2 SD; reflects both chronic and acute malnutrition
• A child can be stunted but not wasted, or both (most severe)

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40. 24-Hour Recall and Food Frequency Methods

• Interview about all food/drinks consumed in preceding 24 hours
• Simple, quick, inexpensive
• Limitation: single day may not reflect usual intake; dependent on memory

• Lists common foods; respondent states how often consumed (daily, weekly, monthly)
• Assesses usual/habitual intake
• Good for epidemiological studies
• Limitation: less precise for quantitative intake

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41. Nutritional Surveillance

1. Define the purpose and target group
2. Select indicators (anthropometric, clinical, biochemical, dietary)
3. Data collection at sentinel sites
4. Data analysis and interpretation
5. Dissemination and action

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42. Assessment of Nutritional Status Using Biochemical and Laboratory Methods

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43. Nutritional Rehabilitation

1. Nutrition Rehabilitation Centres (NRCs): For SAM (severe acute malnutrition) with medical complications - inpatient management
2. Community-based management (CMAM): SAM without complications treated at community level with RUTF (Ready to Use Therapeutic Food - F100 based)
3. WHO SAM Protocol:
   • Phase 1 (stabilisation): F75 feed, treat infections, correct electrolytes
   • Phase 2 (rehabilitation): F100, RUTF, gradual increase in calories
4. ICDS (Integrated Child Development Services): Supplementary nutrition, nutrition education
5. Anganwadi-based nutrition: Growth monitoring, supplementary feeding

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SECTION D: Food Safety

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44. Define Food Safety and Food Hygiene

• Food Safety: Assurance that food will not cause harm to the consumer when it is prepared and/or eaten according to its intended use (WHO)
• Food Hygiene: All conditions and measures necessary to ensure the safety and suitability of food at all stages of the food chain

1. Keep clean
2. Separate raw and cooked
3. Cook thoroughly
4. Keep food at safe temperatures
5. Use safe water and raw materials

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45. Food Processing - Objectives, Methods, Advantages and Disadvantages

• Dehydration/drying
• Canning
• Freeze-drying (lyophilisation)
• High-temperature processing (HTST, UHT)
• Modified atmosphere packaging

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46. Milk and Meat Hygiene

Milk Hygiene

• LTLT (Low Temperature Long Time/Holder method): 63°C for 30 minutes
• HTST (High Temperature Short Time): 72°C for 15 seconds (most common)
• UHT (Ultra High Temperature): 132°C for 1 second

• Methylene blue reduction test (MBRT) - assesses bacterial load
• Phosphatase test - confirms pasteurisation (enzyme denatured at pasteurisation temp)
• Standard plate count (SPC)
• Coliform count
• Specific gravity (lactometer reading) - detects adulteration with water

Meat Hygiene

• Ante-mortem and post-mortem inspection mandatory
• Slaughterhouse hygiene: proper sanitation, refrigeration
• Meat-borne diseases: Salmonellosis, E. coli O157, Trichinosis, Taeniasis, Anthrax, Brucellosis
• Cold chain maintenance essential

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47. Food Additives - Classification and Laws

1. Preservatives: Sodium benzoate, potassium sorbate, sulphur dioxide
2. Antioxidants: BHA, BHT, Vitamin C, Vitamin E
3. Emulsifiers: Lecithin, mono/diglycerides
4. Stabilisers/thickeners: Gelatin, agar, pectin, guar gum
5. Colouring agents: Natural (turmeric) and artificial (erythrosine)
6. Flavouring agents: Natural and synthetic
7. Sweeteners: Saccharin, aspartame, sucralose
8. Acidulants/acidity regulators: Citric acid, acetic acid
9. Nutrient supplements: Vitamins, minerals for fortification

• Food Safety and Standards Act, 2006 (FSSA) - superseded PFA 1954
• FSSAI (Food Safety and Standards Authority of India) - regulatory body
• Prevention of Food Adulteration (PFA) Act, 1954 - now repealed

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48. Food Fortification

• Corrects nutrient deficiencies at population level
• Cost-effective public health intervention
• Doesn't require change in food habits
• Can reach large populations

• Salt + iodine (IDD prevention)
• Wheat flour + iron + folic acid
• Rice + iron + folic acid + Vitamin B12
• Milk + Vitamin D
• Edible oil + Vitamin A

• National Food Fortification Program under FSSAI
• Fortification of rice (distributed through PDS, MDM, ICDS)
• Large Scale Food Fortification under POSHAN Abhiyaan

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49. Food Preservation - Principles and Methods

1. Prevention/delay of microbial decomposition
2. Prevention/delay of self-decomposition (enzymes)
3. Prevention of contamination

1. Low temperature: Refrigeration (4°C), freezing (-18°C), cold chain
2. High temperature: Boiling, pasteurisation, canning, UHT
3. Drying: Sun drying, spray drying, freeze drying
4. Chemical preservation: Salt, sugar, vinegar, sodium benzoate
5. Fermentation: Yogurt, pickles, idli, alcohol
6. Irradiation: Gamma rays, electron beams; kills pathogens, extends shelf life
7. Vacuum/Modified atmosphere packaging
8. Smoking: Combination of heat and chemical action

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50. Food Toxicants

• Lathyrism: Lathyrus sativus (khesari dal) - beta-ODAP toxin - lower limb spasticity/paralysis
• Epidemic dropsy: Argemone mexicana oil adulterating mustard oil - sanguinarine toxin
• Ergotism: Ergot fungus (Claviceps purpurea) on rye - ergot alkaloids - convulsions/gangrene
• Aflatoxins: Aspergillus flavus on groundnuts, cereals - hepatotoxic, carcinogenic (hepatocellular carcinoma)
• Botulism: Clostridium botulinum toxin in improperly canned foods - neurotoxin
• Solanine: Green/sprouting potatoes - GI and neurological symptoms

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51. FSSAI (Food Safety and Standards Authority of India)

• Sets standards for food articles
• Regulates manufacture, storage, distribution, sale and import
• Scientific advice and technical support to government
• Collects and collates data on food consumption
• Promotes food safety awareness
• Issues licenses to food businesses

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52. National Nutrition Policy (1993) and National Nutrition Programmes

• Salient features: Multi-sectoral approach; short-term and long-term strategies
• Short-term: Direct nutrition interventions (supplementation, fortification)
• Long-term: Agriculture, food production, poverty alleviation, women's education, health care

1. ICDS (Integrated Child Development Services, 1975): Supplementary nutrition, immunisation, health check-up, referral, pre-school education, nutrition education - targets 0-6 years + pregnant/lactating women
2. Mid-Day Meal Programme (PM POSHAN, 1995): Free cooked meals in government schools (Class I-VIII); improves enrolment, retention, reduces hunger
3. Poshan Abhiyaan (POSHAN 2.0, 2018): Targets stunting, wasting, underweight, anaemia; convergence approach
4. National Iodine Deficiency Disorders Control Programme (NIDDCP)
5. National Anaemia Control Programme - IFA supplementation
6. Vitamin A Supplementation Programme (NPCB)
7. Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA)

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SECTION E: Environment and Health

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53. Define Environment

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54. Environment as a Determinant of Health

• Water quality (waterborne diseases)
• Air quality (respiratory diseases)
• Food quality (foodborne diseases)
• Vector habitats (vector-borne diseases)
• Occupational hazards
• Climate (heat/cold-related illness)
• Social environment (poverty, stress)

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55. Components of Environmental Health

1. Water and sanitation
2. Air quality (indoor and outdoor)
3. Food safety
4. Waste management (solid waste, biomedical, sewage)
5. Vector and pest control
6. Housing
7. Noise
8. Radiation
9. Occupational health
10. Climate change

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56. Define Safe and Wholesome Water; Water-Borne, Water-Washed, Water-Based and Water-Related Diseases

• Safe water: Free from harmful chemical and biological contamination
• Wholesome water: Safe + aesthetically acceptable (colourless, odourless, tasteless)
• Improved drinking water: Piped, borehole, protected dug well, rainwater collection
• Portable water: Can be safely consumed

1. Water-borne diseases: Transmitted through drinking contaminated water - cholera, typhoid, hepatitis A, dysentery, polio, gastroenteritis
2. Water-washed diseases: Result of insufficient water for hygiene - trachoma, scabies, lice, skin infections, diarrhoea
3. Water-based diseases: Require aquatic intermediate host - schistosomiasis, dracunculiasis (guinea worm), fascioliasis
4. Water-related (vector) diseases: Vectors breed in water - malaria, dengue, filariasis, Japanese encephalitis

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57. Sources of Water, Characteristics, Advantages and Disadvantages

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58. Water Purification Methods

• Storage and sedimentation (removes suspended particles)
• Filtration (sand, ceramic filters)
• Boiling (most reliable household method - kills all pathogens)
• Solar disinfection (SODIS)
• Chemical treatment (chlorine tablets, iodine)

1. Screening/coarse filtration
2. Sedimentation (plain + with coagulants: alum, ferric sulphate)
3. Coagulation/flocculation
4. Filtration: Slow sand filtration (best for removal of bacteria, 99%); Rapid sand filtration (preceded by coagulation)
5. Disinfection: Chlorination (most common); also UV, ozonation

• Bleaching powder: 1 g per 1000 litres (1 ppm residual chlorine)

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59. Water Quality Criteria and Standards

• Turbidity: <1 NTU (for disinfection); <5 NTU (acceptable)
• Color: <15 TCU
• Taste and odour: unobjectionable
• Temperature: cool

• pH: 6.5-8.5
• Total dissolved solids (TDS): <500 mg/L (acceptable); <1000 mg/L (tolerable)
• Fluoride: 0.5-1.5 mg/L
• Nitrates: <50 mg/L
• Arsenic: <0.01 mg/L

• Total coliform count: 0 per 100 mL (treated piped supply)
• E. coli: 0 per 100 mL
• BIS standard (India): Total coliform 0/100 mL; faecal coliform 0/100 mL

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60. Fluoridation of Water

• Optimal fluoride level: 0.5-0.8 ppm (India); 0.7 mg/L (USA)
• Below 0.5 ppm: dental caries risk
• Above 1.5 ppm: dental fluorosis; above 3 ppm: skeletal fluorosis

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61. Sanitation of Swimming Pool

• Free residual chlorine: 0.6-1.5 ppm
• pH maintained: 7.2-7.8
• Recirculation of water through sand filter
• Superchlorination periodically

1. Inlet water filtered and disinfected
2. Recirculation system (every 6-8 hours)
3. Continuous chlorination
4. Regular bacteriological testing

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62. Water Conservation

• Protection of water bodies from pollution
• Rainwater harvesting
• Efficient irrigation (drip/sprinkler)
• Reuse and recycling of treated wastewater
• Reducing losses in distribution systems
• Public awareness

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63. Sources of Water Pollution

1. Sewage and wastewater (domestic)
2. Industrial effluents (heavy metals, chemicals, thermal pollution)
3. Agricultural runoff (pesticides, fertilisers, nitrates)
4. Solid waste leachate
5. Mining activities (acid mine drainage)
6. Oil spills
7. Atmospheric deposition (acid rain)

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64. National Programme for Supplying Drinking Water - Jal Jeevan Mission

• Target: Provide piped water supply (FHTC - Functional Household Tap Connection) to every rural household by 2024
• 55 litres per capita per day
• Part of NMCG (National Mission for Clean Ganga)
• Budget: ₹3.60 lakh crore
• Replaces National Rural Drinking Water Programme (NRDWP)

• Safe and adequate drinking water to all rural areas
• Minimum 40 LPCD

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65. Waterborne Diseases and Their Prevention

• Cholera: ORS, safe water, sanitation, Oral Cholera Vaccine
• Typhoid: Safe water, sanitation, vaccination (Vi polysaccharide vaccine)
• Hepatitis A: Vaccination, safe water
• Dysentery (bacillary/amoebic): Safe water, food hygiene
• Poliomyelitis: OPV/IPV vaccination, safe water
• General prevention: Water treatment (chlorination), sanitation, hand washing (5 critical times)

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66. Define Sanitation; Relate to Health; Enumerate Steps of Handwashing

• Prevents faecal-oral disease transmission (diarrhoea, typhoid, hepatitis A, polio, worm infestations)
• Reduces child mortality
• Improves nutrition (by reducing diarrhoea and intestinal worm load)
• Promotes dignity and safety (especially for women and girls)

1. Wet hands + apply soap
2. Rub palms together
3. Rub right palm over back of left hand, interlacing fingers; repeat for other hand
4. Rub palms together with fingers interlaced
5. Rub backs of fingers of one hand with the palm of the other, locking fingers; repeat
6. Rotationally rub left thumb clasped in right palm; repeat with other thumb
7. Rotationally rub closed fingers of right hand in left palm; repeat
8. Rinse with water; dry with single-use towel; use towel to turn off tap

1. Before eating
2. After using toilet
3. Before/after preparing food
4. After handling faeces (child or adult)
5. Before and after caring for sick person

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67. Solid Waste - Definitions, Classification, Management

• Solid waste: Non-liquid waste arising from domestic, commercial, industrial, and agricultural activities
• Biodegradable waste: Waste that can be decomposed by microorganisms (food scraps, paper, garden waste)
• Non-biodegradable waste: Cannot be decomposed by microorganisms (plastics, metals, glass)
• E-waste: Electronic waste (computers, mobiles, batteries) - contains heavy metals

1. Domestic/household
2. Commercial
3. Industrial
4. Institutional
5. Bio-medical
6. Construction debris

1. Segregation at source: Wet (green bin), Dry (blue bin), Hazardous (black bin)
2. Collection: Door-to-door collection
3. Transportation: To processing sites
4. Processing/Treatment: Composting (organic), Recycling (dry), Incineration (hazardous), Sanitary landfill
5. Disposal

• Open dumping: Oldest, worst method; creates nuisance, disease risk
• Sanitary landfill: Controlled dumping with compaction and daily cover of soil; landfill gas collection possible
• Composting: Biological decomposition of organic waste; produces compost (fertiliser); Vermicomposting (using earthworms)
• Incineration: High-temperature burning; reduces volume by 90%; can generate energy; needs pollution control
• Recycling: Paper, glass, metals, plastics

• Launched: October 2, 2014
• Phase 1 (SBM-G1): Open Defecation Free India by 2019
• Phase 2 (SBM-G2): Sustain ODF + solid and liquid waste management
• Construction of household toilets, community toilets, sanitary complexes

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68. Excreta Disposal

1. Pit privy (simple pit latrine): Oldest method; low cost; not suitable for high water table areas
2. Bored-hole latrine: For rural areas with low population density
3. Aqua privy: Septic tank beneath toilet seat
4. Septic tank: Anaerobic treatment of sewage; effluent to soak pit
5. Pour-flush latrine: Most acceptable in India; uses small amount of water to flush
6. Sanitary latrine (water-seal): Odour-free, fly-free
7. Sewage system: Waterborne carriage (sewerage)

• Wash hands with soap after defecation
• Keep toilet clean
• Use enclosed/water-seal latrines

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69. Biomedical Waste Management

• Biomedical waste: Any waste generated during diagnosis, treatment, or immunisation of human beings or animals, or in research activities pertaining thereto, or in the production or testing of biological products
• Hospital waste: All waste generated in healthcare setting

1. Segregation at source (most critical step)
2. Collection and packaging
3. Storage (max 48 hours in smaller, 72 hours in larger facilities)
4. Transportation (within hospital and to CBMWTF)
5. Treatment and disposal (incineration, autoclaving, shredding)

• Incineration (temperature 800-1200°C) - anatomical waste
• Autoclaving/steam sterilisation - infectious waste
• Chemical disinfection
• Microwave treatment
• Secure landfill for inert waste

• Supersedes BMW Rules 1998
• Covers all healthcare facilities
• Every HCF must have a colour-coded system
• Bar-coded bags for tracking
• Annual report to State Pollution Control Board

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70. Air Pollution and Health

1. Outdoor (ambient) air pollution
2. Indoor air pollution (household air pollution)

• Particulate matter (PM2.5, PM10): most important; penetrates deep into lungs
• Ozone (O3)
• Nitrogen dioxide (NO2)
• Sulphur dioxide (SO2)
• Carbon monoxide (CO)
• Lead (Pb)
• Benzene, PAHs, dioxins

• Vehicular emissions
• Industrial emissions (thermal power plants)
• Domestic combustion (burning biomass, coal)
• Agricultural burning
• Construction dust

• Respiratory irritation, cough, bronchospasm
• Exacerbation of asthma and COPD
• Cardiovascular events (MI, stroke)

• Chronic bronchitis, COPD
• Lung cancer (PM2.5, PAHs)
• Cardiovascular disease
• Reduced lung function

• 0-50: Good
• 51-100: Satisfactory
• 101-200: Moderate
• 201-300: Poor
• 301-400: Very Poor
• 401-500: Severe

• Source control (clean fuels, emission standards)
• Bharat Stage (BS-VI) emission norms for vehicles
• End-of-pipe treatment (electrostatic precipitators, scrubbers)
• Urban planning (green belts)
• National Clean Air Programme (NCAP) - target 20-30% reduction in PM by 2024

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71. Indoor Air Pollution

• COPD, chronic bronchitis
• Acute lower respiratory infections (ALRI) in children
• Lung cancer (women)
• Low birth weight
• Cataracts

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72. Ventilation and Health

• Accumulation of CO2 and body odours
• Increased humidity → respiratory infections
• Sick Building Syndrome
• Headache, fatigue, poor concentration

1. Natural ventilation: Cross-ventilation through doors and windows; dependent on wind
2. Artificial ventilation: HVAC systems, exhaust fans
3. Plenum system: Fans push air into corridors at high pressure

• Air change rate: 6-10 air changes/hour in hospitals
• CO2 not to exceed 0.1% (1000 ppm)
• Temperature: 18-24°C
• Relative humidity: 40-60%
• Window area: 1/10 of floor area (10% rule)

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73. Radiation and Health

• Natural (background): Cosmic rays, terrestrial (radon), internal (K-40, C-14) - accounts for ~85% of human exposure
• Man-made: Medical X-rays (largest man-made source), nuclear power plants, industrial radiography, nuclear weapons testing

1. Ionising radiation: X-rays, gamma rays, alpha, beta particles - can ionise atoms; harmful
2. Non-ionising radiation: UV light, infrared, microwave, radiofrequency, ELF - cannot ionise; can cause thermal damage

• Somatic effects: Occur in exposed individual - leukaemia, thyroid cancer, solid tumours, radiation sickness (acute: nausea, vomiting, bone marrow failure)
• Genetic/heritable effects: Mutations passed to offspring
• Deterministic effects (threshold): Severity increases with dose above a threshold (e.g. radiation burns, cataract)
• Stochastic effects (no threshold): Probability increases with dose (cancer, genetic mutations)

1. Time: Minimise time of exposure
2. Distance: Maximise distance from source (inverse square law)
3. Shielding: Lead aprons, concrete walls
4. Dosimetry: TLD badges for occupational monitoring
5. AERB (Atomic Energy Regulatory Board) - regulates radiation safety in India

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74. Light and Health

1. Natural light (sunlight): Visible spectrum + UV + IR
2. Artificial light: Incandescent, fluorescent, LED

• Ultraviolet (UV) B (280-315 nm): Vitamin D synthesis (beneficial); sunburn, cataract, skin cancer (harmful)
• UV-A (315-400 nm): Tanning, photoageing, skin cancer
• Visible light: Circadian rhythm regulation (blue light), mood
• Infrared (IR): Heat - cataract (chronic exposure)

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75. Housing and Health

• Adequate space per person (min 9-12 m² per person)
• Proper natural lighting (window area = 1/10 floor area)
• Cross-ventilation
• Safe water supply within/near house
• Sanitary latrine
• Protection from weather, insects, rodents
• Structurally sound
• Free from dampness

• Economic status
• Urban/rural setting
• Land availability and affordability
• Building regulations and enforcement

• Overcrowding: facilitates airborne disease transmission (TB, measles, influenza)
• Damp houses: respiratory infections, rheumatism
• Inadequate light: rickets (vitamin D), eye strain
• Poor sanitation: enteric diseases
• Insect/rodent infestations

• Increased transmission of respiratory infections (TB, influenza, meningococcal disease)
• Increased mental health problems
• Domestic violence
• Accidents

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76. Climate Change and Global Greenhouse Effect on Health

• Direct: Heat waves → heat stroke, cardiovascular deaths (Paris 2003: 15,000 deaths)
• Indirect: Changes in vector distribution (malaria, dengue expanding to new areas), water scarcity, food insecurity, natural disasters (floods, droughts), displacement
• Mental health effects
• Sea level rise → displacement, saltwater intrusion

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77. Laws on Environmental Pollution in India

1. Environment (Protection) Act, 1986 - comprehensive umbrella legislation
2. Water (Prevention and Control of Pollution) Act, 1974 - Central/State Pollution Control Boards
3. Air (Prevention and Control of Pollution) Act, 1981
4. Forest Conservation Act, 1980
5. Wildlife Protection Act, 1972
6. Hazardous Waste Management Rules, 2008
7. Biomedical Waste Management Rules, 2016
8. Solid Waste Management Rules, 2016
9. National Green Tribunal (NGT) Act, 2010 - specialised environmental court
10. CPCB (Central Pollution Control Board) - apex body; SPCBs at state level

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78. Temperature and Health

Heat-Related Illnesses

• Core body temperature >40°C; CNS dysfunction; absence of sweating (classic)
• Emergency management: Rapid cooling (ice packs to neck, axilla, groin; cold water immersion); IV fluids; hospital admission
• Homeopathic management (for exam context): Belladonna, Gloninum, Natrum carb

• Due to water/salt depletion; profuse sweating; normal or slightly elevated temperature
• Management: Rest, cool environment, oral rehydration; if severe - IV fluids

• Avoid outdoor activity 11 am - 4 pm in summer
• Adequate hydration
• Wear light-coloured, loose clothing
• National Action Plan on Heat-related Illness (India)

Cold-Related Illnesses

• Mild: 32-35°C; shivering
• Moderate: 28-32°C; no shivering; confusion
• Severe: <28°C; coma, cardiac arrest

• Superficial: Skin blanching, numbness; reversible
• Deep: Tissue necrosis; amputation may be needed

• Warm layered clothing
• Dry conditions
• Adequate nutrition and shelter
• Know warning signs

• Move to warm environment
• Remove wet clothing
• Warm passively (blankets) then actively (warm fluids)
• Do NOT rub frostbitten area
• Hospitalise severe cases

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79. High Altitude Effects

• Acute Mountain Sickness (AMS): Headache, nausea, dizziness, fatigue (>2500m)
• High Altitude Pulmonary Oedema (HAPO): Most common life-threatening condition; >3500m; hypoxia + increased pulmonary vascular resistance
• High Altitude Cerebral Oedema (HACO): Ataxia, confusion, coma
• Chronic Mountain Sickness (Monge's disease)

• Acclimatise gradually (ascend <300-500m per day above 3000m)
• Acetazolamide 250 mg BD (prophylaxis)
• Avoid alcohol and sedatives
• Good physical fitness

• Descend immediately
• Supplemental oxygen
• Gamow bag (portable hyperbaric chamber)
• Dexamethasone for HACO
• Nifedipine for HAPO

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SECTION D: Social & Behavioural Health

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80. Define Sociology, Community, Culture, Customs, Acculturation

• Sociology: Study of society, social institutions, and social relationships; how groups function and interact
• Community: A social group sharing territory, history, culture, and common interests; can be geographical or functional
• Culture: The shared values, beliefs, customs, behaviours and artifacts that members of a society use to interact with each other
• Customs: Traditional practices and social behaviours handed down within a group
• Acculturation: Process of cultural and psychological change through contact between two cultures; one group (usually minority) adopts elements of the dominant culture

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81. Health Behaviour - Illness Behaviour, Sick Role Behaviour, Health Risk Behaviour

• Health behaviour (Kasl & Cobb): Any activity undertaken by a person believing herself/himself to be healthy for the purpose of preventing disease or detecting it in an asymptomatic stage
• Illness behaviour: Activity of an ill person to define their illness and seek a remedy - how a person perceives, evaluates, and acts upon symptoms
• Sick role behaviour (Parsons, 1951): The pattern of behaviour expected of a person who is ill; includes:
  • Exemption from normal role responsibilities
  • Not held responsible for illness
  • Obligated to seek treatment and cooperate
  • Obligated to want to get well
• Health risk behaviour: Behaviours that increase the probability of illness, injury, or death - smoking, excessive alcohol, unsafe sex, drug abuse, poor diet, physical inactivity

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82. Principles of Behaviour Change

• Health Belief Model (Rosenstock): Behaviour change depends on perceived susceptibility, severity, benefits, and barriers
• Stages of Change (Transtheoretical Model - Prochaska): Pre-contemplation → Contemplation → Preparation → Action → Maintenance → Relapse
• Social Cognitive Theory (Bandura): Self-efficacy is key; observational learning, role modelling
• Theory of Planned Behaviour: Behaviour driven by intention, which is shaped by attitudes, subjective norms, and perceived behavioural control

1. Readiness to change must be assessed
2. Behaviour change is a process, not an event
3. Social support enhances change
4. Self-efficacy is essential
5. Positive reinforcement works better than punishment

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83. Health-Seeking Behaviour; Factors Influencing; Barriers

• Perceived severity of illness
• Cultural beliefs and past experiences
• Availability and accessibility of services
• Cost (economic barrier)
• Educational level
• Gender and age
• Previous experience with healthcare
• Social support

1. Demand-side: Low awareness, cultural beliefs, stigma, cost, distance, transport
2. Supply-side: Shortage of providers, poor quality, lack of medicines, inconvenient hours
3. Information barrier: Low health literacy

• Health education and IEC (Information, Education, Communication)
• ASHA workers (community health workers)
• Mobile health clinics
• Free/subsidised services
• Reducing stigma through community engagement
• Telemedicine

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84. Medical Sociology

• Understanding patient's social context for better care
• Identifying social determinants of illness
• Doctor-patient relationship
• Health behaviours influenced by social factors
• Community participation in health

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85. Social Psychology in Community Medicine

• Understanding group behaviour and community norms
• Designing health communication campaigns
• Behaviour change communication
• Social support and its health effects
• Stigma and discrimination in health

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86. Social Determinants of Health and Disease

1. Income and social status
2. Education level
3. Employment and working conditions
4. Social support networks
5. Physical environment (housing, community)
6. Health behaviours
7. Access to health services
8. Culture and ethnicity
9. Gender
10. Early childhood development

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87. Role of Social-Cultural Factors in Health and Disease

• Positive: Cultural food practices (haldi/turmeric - anti-inflammatory); yoga; social support in families
• Negative: Female infanticide; boy preference → malnutrition in girls; taboos preventing nutritious food in pregnancy; stigma around mental illness/HIV; faith healers delaying treatment; consanguineous marriages (genetic disease); early marriage → maternal mortality; caste-based discrimination in health access

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88. Define Community; Classify as per Brint; Types

1. Community of place: People sharing a geographical area (village, neighbourhood)
2. Community of interest: People sharing common interests or characteristics regardless of location (professional community, ethnic community)

• Rural community
• Urban community
• Suburban community
• Nomadic community
• Virtual/online community

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89. Define Community Behaviour; Community Behaviour Discipline; Community Relationship/Engagement

• Community behaviour: Collective actions and patterns of a community group in response to circumstances
• Community behaviour discipline: The expectation that individuals within a community follow norms and rules for the collective good; essential for effective public health interventions (e.g., vaccination coverage, sanitation compliance)
• Community relationship/engagement: Purposeful collaboration with community members to address issues affecting their health and well-being; involves genuine participation, not just consultation

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90. Justify the Need and Importance of Community Relationships for Health Education in the Community

• Community trust is prerequisite for health education acceptance
• Local leaders and influencers have greater credibility than outside experts
• Engagement ensures culturally appropriate messaging
• Community-identified priorities get better participation
• Sustainable health behaviour change requires community ownership
• ASHA and ANM programmes work because of embedded community relationships

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SECTION F: Health Infrastructure in India

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91. Health Infrastructure at Sub-Centre, PHC, CHC, Ayushman Bharat HWC, District Hospital Level

Sub-Centre (SC)

• Peripheral unit: covers 5,000 population (3,000 in hilly/tribal)
• Staff: 1 ANM (female) + 1 Male Health Worker (MPW-M)
• Provides: Maternal and child health, family planning, immunisation, basic first aid, DOTS, referral

Primary Health Centre (PHC)

• Covers 30,000 population (20,000 hilly/tribal)
• Staff: 1 Medical Officer (MBBS) + 14 paramedical staff
• First contact with medical officer
• 6 beds; OPD + basic lab + MCH + family planning

Community Health Centre (CHC) / FRU

• Covers 1,20,000 population (80,000 hilly/tribal) = 4 PHCs
• 30 beds
• 4 specialists: physician, surgeon, gynaecologist, paediatrician
• FRU (First Referral Unit): Capable of EmOC, blood transfusion, surgery - this is the CHC upgraded

Ayushman Bharat - Health and Wellness Centres (AB-HWC)

• Launched 2018
• Sub-centres and PHCs upgraded to HWCs
• 12 expanded service packages (beyond MCH): NCD screening, mental health, palliative care, AYUSH
• Community Health Officer (CHO) - mid-level provider

District Hospital

• Covers 1 district (~1-2 million)
• Secondary level referral
• 200-500 beds
• All specialities available
• CMO (Chief Medical Officer) in charge

Taluk Hospital

• Between PHC and district hospital
• 100-200 beds
• Basic specialist services

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92. First Referral Unit (FRU)

• Blood transfusion services
• Caesarean section
• Management of obstetric complications (PPH, eclampsia, obstructed labour)
• Safe abortion services

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93. BEMOC and CEMOC

• BEmOC (Basic Emergency Obstetric Care): 6 signal functions:
  1. Administer parenteral oxytocics
  2. Parenteral anticonvulsants (MgSO4)
  3. Parenteral antibiotics
  4. Manual removal of placenta
  5. Removal of retained products of conception
  6. Assisted vaginal delivery (vacuum/forceps)
• CEmOC (Comprehensive Emergency Obstetric Care): All 6 BEmOC functions + Caesarean section + Blood transfusion

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Summary Quick-Reference Table (Important Exam Terms)

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Topics Covered (All from Park's Textbook)