SEMINAR ON

PATHOPHYSIOLOGY
AND PSYCHODYNAMICS
OF DISEASE CAUSATION

SUBMITTED TO SUBMITTED BY
Mrs. Priyadarshini Madam P. Lavanya
Lecturer M.Sc (N) 1st Year
Govt. College of Nursing Govt. College of Nursing
Somajiguda. Somajiguda.
 STUDENT PROFILE

Name of the student : P.Lavanya

Course : M.Sc Nursing
Year : II year
Subject : Advanced Nursing Practice
Unit :
Topic : Pathophysiology and psychodynamics
Of disease causation
Method of teaching : Lecture Method
Group : M.Sc Nursing 1st year
Place : 1st Year classroom
Date :
Duration : 1 ½ hour
A.V aids : OHP, Black board, Flashcards, PPT,
Charts.
 OBJECTIVES
General Objectives:
By the end of the class the students will be able to gain in-depth knowledge
regarding pathophysiology and psychodynamics of disease causation
Specific objectives:
The students will be able to..
• Introduction and definition of health
• List out the determinants of health
• Define the disease and psychodynamics
• Explain the causation of disease
• Discuss the theories of causation of disease
• Explain the pathogenesis of disease
• Discuss the iceberg phenomenon
• Explain all the health related diseases stress and coping strategies
 INTRODUCTION TO HEALTH
Health is the level of functional or metabolic efficiency of a living being.
In humans, it is the general condition of a person’s mind, body and spirit, usually
meaning to be free from illness, injury or pain.
When the body is threatened or suffers an injury its response may involve
functional that the body can mount will determine between adaptation and
maladaptation.

DEFINITION OF HEALTH
The term health has been defined in a variety of ways. Health is a state of
complete physical, mental and social well being and not merely the absence of
disease or infirmity”
- WHO

Health is a state of dynamic balance of an individual’s ability to perform

personally valued roles and responsibilities, to deal and cope with physical,
biological, psychological and social stresses and challenges thought the life while
continuing to maintain sense of well being”
- According to ICN

DETERMINANTS OF HEALTH

➢ HUMAN BIOLOGY
➢ ENVIRONMENT
➢ LIFESTYLE
➢ HEALTH AND HEALTH ALLIED RESOURCES
➢ HUMAN BIOLOGY
• Genetic inheritance and physiological factors- Physiological factors
involve the physical functions of the body. Certain physical condition such
 as being pregnant or overweight place an increased risk of stress on
physiological system increasing susceptibility to illness in that area.
• Hereditary or genetic predisposition to specific illness is a major physical
risk factors. Eg. A family history of diabetes mellitus is at risk of developing
disease later in life. Other genetic risk factor include family history of cancer,
heart disease or mental illness.
• Age –Age increases or decreases susceptibility to get illness. Eg: An infant
born prematurely and neonates are more susceptible to infection. The risk of
heart increases with age for both sex.
➢ ENVIRONMENT
• Micro-environment-Refers to immediate environment or personal
environment usually include home environment, occupational environment,
socio-cultural environment.
• Macro-environment-External environment which is outside the home
environment.
• Physical environment-It includes housing; building structures and wide
variety of physical substances which directly or indirectly regulate body
mechanism and affect heath.
• Social environment-It includes other people and social institutions, socio-
cultural events, religious beliefs, moral and ethical values and social rules and
regulations pertaining to living in the society. The individuals develop certain
practices which will have positive and negative impact on heath.
• Biological environment-It is comprised of plant and animal kingdom which
help in maintaining the ecosystem and thereby heath of people.
➢ LIFE STYLE

Life style refers to the people’s ways of living which is reflective of their
knowledge, attitude and practices. It is composite of daily living activities,
behavioural and cultural practices including customs and traditions. E.g.-
unhygienic practices, nutritional deficiencies, smoking, alcoholism etc .

➢ HEALTH AND HEALTH ALLIED RESOURCES

• Socio-economic conditions-It includes economic status, education,
occupation and living standard.
• Political system-It has a very strong role in promotion of people in the
country. The heath care delivery system is determined by the political system
through there is constitutional control.
• Heath related services-It includes education, food and agriculture, industry,
rural and urban development, social welfare and manpower development,
communication and broadcasting and transportation etc.

PATHO-PHYSIOLOGY AND PSYCHODYNAMICS OF DISEASE

CAUSATION

DISEASE

Disease is just the opposite of the health “Disease is a condition in which

body health is impaired, a departure from the state of health, an alteration of
human body interrupting the performance of vital functions”

Webster.

The Oxford English Dictionary defines decease as, “a condition of the

body or some part or organ of the body in which its functions are disrupted or
deranged.”

Pathophysiology

It is the physiology of altered health. The term combines pathology and

physiology. Pathology deals with the study of structural and functional changes
and physiology deals with the functions of the human body.
Psychodynamics

• It is a systematized study and theory of the psychological forces that

underlie human behaviour, emphasizing the interplay between conscious
& unconscious motivation.
• It is defined as human behaviour, either external or internal which can lead
to its state of health or disease.
• The original concept of psychodynamics was developed by “Sigmund
Freud”. Psychodynamics also known as dynamic psychology.It is the study
of the interrelationship of various part of mind, personality or psyche in
relation to mental, emotional or motivational forces.

CONCEPT OF DISEASE CAUSATION-

Includes theories of disease causation, pathogenesis and iceberg

phenomenon.

Theories of disease causation:

❖ Old theories
❖ Germ theory of disease
❖ Biomedical model
❖ Theory of multifactorial causation
❖ Epidemiological triad
❖ Lazaru’s theories of stress response
❖ Wolff’s theory of stress, organ maladaptation and disease
❖ Holmes and Rahe’s theory of life change and the onset of illness

OLD THEORY
▪ Old Theories- Till the end of 18th century, various theories were in vogue,
e.g. supernatural theory of disease (e.g. curse of God; an evil eye).
▪ The Ayurveda considers that the disease is due to imbalance of the
“tridoshas.” These are Vata (air), pitta (bile) and kapha (mucus).
▪ The Chinese medicine believes that the disease is caused due to imbalance
of male principle (yang) and female principle (yin).

GERM THEORY
▪ The discoveries in microbiology became a turning point in the etiological
concept of disease.
▪ Louis Pasteur(1860) demonstrate the presence of bacteria in the air.
▪ Robert Koch (1877) showed the anthrax was caused by bacteria.
▪ These theories of Pasteur and Koch confirmed the germ theory of disease
▪ Thus the emphasis has shifted from empirical causes (like bad air as cause
in malaria)of the old theories to microbes of Germ theory.
▪ But now, it is recognized that a disease is rarely caused by a single agent
alone, but depends upon a number of contributory factors.

BIOMEDICAL MODEL
▪ This model explains disease as a result of malfunctioning organs or cells
.e.g. diabetes is caused by malfunctioning of pancreas.
▪ But the drawback with it is that it focuses on cause and effect relationships,
tends to ignore the psychosocial component of the disease.

THEORY OF MULTIFACTORAL CAUSATION

▪ This theory of multifactorial causation was put forth by Pettenkofer
Munich (1819-1901).
▪ Disease is not caused by an organism but predisposed by many factors
contributing to its occurrence, specially “modern diseases” of civilization
▪ These predisposing factors are:-social, economic, cultural, genetic,
psychological factors, etc.(including poverty, illiteracy, ignorance, poor
living condition, over-crowed)
▪ This theory de-emphasizes the “Germ theory” (or single cause idea).
▪ It is now known that most of these factors are so much linked to life-style
and human behavior, that they are considered as “Risk-factors”, in the web
of causation of the disease.

WEB OF CAUSATION
▪ It was suggested by MACMAHON and PUGH.
▪ This model is ideally suited in study of chronic diseases where disease
agent is not known but is outcome of interaction of multiple factors.
▪ It considers all predisposing factors of any type and there interrelationship
with each other. E.g Myocardial infarction.

EPIDEMIOLOGICAL TRIAD
Environment which are equally important to determine whether or not
disease will occur in the exposed host. This demanded a broader concept
of disease that synthesized the basic factors of agent, host and environment.

LAZARU’S THEORIES OF STRESS RESPONSE

According to him, in the process of coping , the individual shapes as well

as responds to a demand or stress which can have an impact on the client’s
resistance to disease
 WOLFF’S THEORY OF STRESS, ORGAN MALADAPTATION AND
DISEASE
He studied people’s responses to chronic stressors, like a frustrating job or an
unhappy home life. He believed that a person’s total life situation, profoundly
affects a person’s susceptibility to disease

HOLMES AND RAHE’S THEORY OF LIFE CHANGE AND THE

ONSET OF ILLNESS
▪ They explored the relationship between the amount if change in a person’s
life and subsequent illness.
▪ They discovered that the higher a person’s life change score, the greater
the likelihood that an illness would develop

PATHOGENIES OF THE DISEASE

• Prepathogenesis phase
• Pathogenesis phase

PREPATHOGENESIS PHASE
This phase refers to the period before the onset of disease. During this
phase, interaction is taking place among the three components of epidemiological
triad namely agent, host and environment, each representing the angle of
triangle respectively.

As long as there is equilibrium among these three interacting factors, so

long the person will be healthy. Once the equilibrium is disturbed, disease
process starts. In other words, potentially we are all in pre-pathogenesis phases
of many diseases, both communicable and non-communicable.
Agent factor

• Physical agent-heat, cold, radiation, humidity

• Chemical agent-endogenous:urea, uric acid, calcium oxalate
• Exogenous:dust, allergens, gas
• Biological agent-viruses, bacteria etc
• Mechanical agent-friction, injury, accidents
• Nutritional agent

Host factor

• Age
• Sex
• Ethnicity
• Occupation
• Literacy rate
• Income
• Marital status
• Nutritional status
• Lifestyle factor

Environment factor

• Physical environment-air,water,soil,food
• Biological environment-plants,animals,insects, microbes
• Socio-cultural environment-death or divorce of parents, loss of
employment, etc.

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.
• The infection may be clinical or sub clinical, and when the sub clinical, the
person will not have a recognizable signs and symptoms but may spread
the disease agent to others, acting as a “carrier”, as in typhoid, diphtheria.
• When the person develops clinical signs and symptoms, he is called as a
“clinical case”.

ICEBERG PHENOMENON

• To this disease can be closely related with an iceberg. The floating tip of
iceberg represents what physician sees in the community i.e clinical cases.
• The vast submerge portion of the iceberg represents the hidden mass of
disease i.e latent, unapparent, presymptomatic and undiagnosed cases and
carrier in the community. The waterline represents the demarcation
between apparent and unapparent diseases.

Role of nurse in prevention of disease

• Participation in early diagnosis and treatment.

• Notification of certain specific diseases
• Identification of source of infection and method of spread
• Health education of people in general
• Control of communicable diseases.
STRESS

DEFINITION

Stress is an internal state that can be caused by physical demands on body

(disease conditions, exercise, extremes of temperature etc.) or by the
environmental and social situations which are evaluated as potentially harmful,
uncontrollable or exceeding our resources for coping.

The physical, social and environmental causes of stress state are termed as
stressors. One induced by stressors, internal stress state can lead to various
physical bodily responses and psychological responses like depression, anxiety
or hopelessness.

Stressors

A little stress is helpful in coping and to adjust but beyond the limit it
becomes ‘distresses. Main stressors causing distress are:-

• Physical stressors such as injury , infections , exercise, noise and

climatic changes

• Social stressors are family, social activities , health and financial

conditions

• Psychological stressors includes frustration, conflicts etc.

GENERAL ADAPTATION SYNDROME

Body’s response to stressors is called “general adaptation syndrome”. It

consists of three stages:-
1. Alarm reaction
2. Stage of resistance
3. Stage of exhaustion
4. ALARM REACTION
It is essentially the emergency response of body. In this stage, prompt
responses of the body, many of them mediated by the sympathetic nervous
system, preparing the body to cope with stressors.

2. STAGE OF RESISTANCE
• If stressor continues to be present, stage of resistance begins, where body
resists the effect of continuous stressors /stimuli.
• During this stage, certain hormonal responses of the body are important
line of defence in resisting the effects of stressors or stimuli.
• Mainly ACTH (adrenocorticotrophic hormone) is important and more
active among hormonal response.
• Secretion of ACTH is controlled by CRF (corticotrophin releasing factor),
made by cells of brain structure (hypothalamus).
• Stressors/stimuli stimulate hypothalamus to release more CRF, in turn
increasing the secretion of ACTH from pituitary glands.
• ACTH stimulates adrenal gland to secrete steroid hormones such as
cortisol into the blood.
• Cortisols adaptively deal with stressors or stimuli for long period of time
but maintenance for long period of time may be harmful.
• Prolonged elevation of cortisol levels results in elevated blood
pressure and other hormones in excess may have their own harmful actions
which may worsen the body’s response to stimulus.

5. STAGE OF EXHAUSTION
Final stage of general adaptation syndrome is the stage of exhaustion. In
this stage, the body’s capacity to respond to both continuous and new
stressors/stimuli is seriously compromised. For eg: - due to actions of cortisol,
person may not be longer able to ward off infection and becomes sick and die.

SOURCES OF STRESS

There are many sources of stress. They are broadly classified a

• Internal stressors, which arise from within the body like infection,
feelings of depression.
• External stressors originate outside of individual like transfer to another
city, or death in family or any pressure from peer.
• Developmental stressors occur at predictable times throughout
individual’s life.
• Situational stressors are unpredictable and may occur at any time.
Examples are:Death of family member,Marriage or divorce,Birth of
child,New job,Illness.

EFFECTS OF STRESS

Stresses have physical, emotional, intellectual, social and spiritual

consequences. Usually effects are mixed as stress affects whole of the body.

• Physically, stress can threaten person’s physiologic homeostasis.

• Emotionally, it can produce negative or self-destructive feelings about self.
• Intellectually, stress can influence person’s problem solving abilities and
perceptual abilities.
• Spiritually, stress can challenge one’s beliefs and values.

MANIFESTATIONS
 ✓ Pupils dilate to increase visual perception when serious threats to body
arise.
✓ Diaphoresis increases to control elevated heat due to increase metabolism.
✓ Heart rate and cardiac output increases to transport nutrients and by
products effectively
✓ Pallor skin due to vasoconstriction of blood vessels due to effect of nor
epinephrine.
✓ Sodium and water retention increases due to release of mineral corticoids ,
which increases blood volume,
✓ Respiratory rate increases in rate and depth due to vasodilation causing
hyperventilation.
✓ Urine output decreases.
✓ Dry mouth
✓ Decreased peristaltic movements
✓ Mental alertness improves.
✓ Increased muscle tension.
✓ Blood sugar increases due to release of glucocorticoids and
gluconeogenesis.

COPING WITH STRESS

Coping may be described as dealing with change-successfully or
unsuccessfully. Coping strategies is a natural or learned way of responding to
a changing environment or specific problems or situation. Or coping is
cognitive and behavioural effort to manage specific external and/or internal
demands that are appraised as exceeding or taxing the resources of the person.
Coping strategies can be long term and short term.
• Long term coping strategies can be constructive and realistic. For
example, in any situation talking with others or trying to find out more
about situation.
 Others include changes in lifestyle pattern such as eating a healthy diet,
exercising regularly, using problem solving in decision making instead of
anger etc.
• Short term strategies can reduce stress to a tolerable limit temporarily but
are ineffective ways to permanently deal with reality. They may have
destructive effects on the person.
Examples are using alcoholic beverages or drugs, daydreaming, etc.
Coping mechanisms can be adaptive or maladaptive.
• Adaptive coping help the person to deal effectively with stressful events
and minimizes distress associated with them.
• Maladaptive coping can result in unnecessary distress for person.

NURSING MANAGEMENT
Nurse needs to remember that coping is always purposeful. The effectiveness of
person’s coping is influenced by number of factors. Including
▪ Number ,duration and intensity of stressors
▪ Past experiences of individual
▪ Personal qualities of individual.
▪ Support systems available to individual.

1. ASSESSMENT:- Assessment includes

Nursing history:- It includes questions related to client perceived stressors or
stressful events , past and present strategies and signs of stress.
Physical examination for indicators of stress like nail biting , nervousness
,weight changes or stress related problems like hypertension , dyspnea.

2. DIAGNOSIS:- It includes
• Anxiety due to stressors
• Compromised family coping
 • Fear related to perceived threat
• Impaired adjustment to situation
• Ineffective coping
• Post trauma syndrome

3. PLANNING:-Nurse must develops plans in collaboration with patient and

significant support people according to client’s health state , level of anxiety,
support resources, coping mechanisms.
4. IMPLEMENTATION:- Nurse can choose one of these methods of intervention
that will be effective for client .
5. Health promotion strategies :- it includes:-
• Exercise helps to relieve tensions , promotes a feeling of well being and
relaxation
• Optimal Nutrition helps in increasing the body’s resistance to stress.
People need to avoid excess of caffeine , salt, sugar and fat and deficiencies in
vitamins and minerals .
• Sleep helps in restoring the body’s energy levels and managing stress.
• Time management helps in less stress situations.

❖ Minimizing anxiety:- nurses must carry out measures to minimize anxiety

and stress of patient for example , encourage the patient to take deep breaths
before giving injections or massaging the client to relax.

❖ Using relaxation techniques: - several relaxation techniques are used to

relax the mind and tension . Nurse should encourage the clients to use these
techniques in stressful situations like during child birth, before and during painful
procedures or postoperatively to cope with pain. These techniques includes:-

Breathing exercises
 Massage
Progressive relaxation
Yoga
Meditation
Music therapy
Humour and laughter therapy.
These are the various strategies which can be used to deal with stress and person
will be able to prevent and minimize the effects of stressors on the body.

HOROMONAL RESPONSE

Sympathetic nervous system response:

Its response is rapid and short-lived. Nor-epinephrine is release at nerve

endings that are in direct contact with their respective organs to cause and
increase in function of the vital organs and state of general body arousal. Increase
heart rate, Peripheral vasoconstriction , raising blood pressure, blood glucose is
increased, pupils dilated. The purpose of this reponse is to provide better
perfusion to the vital organs.

Sympathetic-adrenal-medullar response:

In addition to its effect on major end organs, sympathetic nervous system

also stimulate the medulla of the adrenal gland to release the hormones
epinephrine and nor epinephrine into the blood stream. The action is similar to
the sympathetic nervous system and has the effect of sustaining and prolonging
its actions. These catecholamines stimulate the nervous system and produce
increase in blood glucose level and increase metabolic rate.

Hypothalamic-pituitary response :

The longest-acting phase of the physiologic response which occur in

persistant stress, involves the hypothalamic pituitary path way. The
hypothalamus secretes corticotrophin releasing factor which stimulates anterior
pituitary to produce ACTH, which in turn stimulates adrenal cortex. Cortisol
stimulates protein catabolism releasing amino acids,stimulates liver uptake of
amino acids and their conversion to glucose and inhibit glucose uptake by many
body cells but not those of the brain and heart. These cortisol induced metabolic
effects provide body with a ready source of energy during a stressful stimulation

HOMEOSTATIC MECHANISMS OF BODY

Homeostatic mechanisms control a property of all living things called

homeostasis. Homeostasis is a built-in, automated, and essential property of
living systems. Breathing is an example of a homeostatic property. Homeostatic
mechanisms are self-regulating mechanisms that function to keep a system in the
steady state needed for survival. These mechanisms counteract the influences that
drive physiological properties towards a more unbalanced state Conditions that
are regulated in homeostasis include blood glucose level, temperature, water
content of the body, and the amount of carbon dioxide and urea being carried by
the blood.

DEFINITION

• Homeostasis, from the Greek words for “same” and “steady,” refers to any
process that living things use to actively maintain fairly stable conditions
necessary for survival.

• It is define by Claude Bernad and later Walter cannon in 1926 is the

property of a system, either open or closed, that regulates its internal
environment and ends to maintain a stable, constant condition. Multiple
dynamic equilibrium adjustment and regulation mechanisms make
homeostasis possible.

• The tendency of a system, esp. the physiological system of higher animals,

to maintain internal stability, owing to the coordinated response of its parts
 to any situation or stimulus tending to disturb its normal condition or
function.

• A state of psychological equilibrium obtained when tension or a drive has

been reduced or eliminated.

Internal components of homeostasis

• Concentration of oxygen and carbon dioxide

• Ph of the internal environment

• Concentration of nutrients and waste products

• Concentration of salt and other electrolytes

• Volume and pressure of extracellular fluid

Components of a homeostatic mechanism

Stimulus Receptors

Control Center

Effectors
Response

Control Systems of homeostasis

Extrinsic
 Most homeostatic systems are extrinsic: they are controlled from outside
the body. Endocrine and nervous systems are the major control systems in higher
animals.

The nervous system depends on sensors in the skin or sensory organs to

receive stimuli and transmit a message to the spinal cord or brain. Sensory input
is processed and a signal is sent to an effector system, such as muscles or glands,
that effects the response to the stimulus.

The endocrine system is the second type of extrinsic control, and involves
a chemical component to the reflex. Sensors detect a change within the body and
send a message to an endocrine effector (parathyroid), which makes PTH. PTH
is released into the blood when blood calcium levels are low. PTH causes bone
to release calcium into the bloodstream, raising the blood calcium levels and
shutting down the production of PTH.

Some reflexes have a combination of nervous and endocrine response. The

thyroid gland secretes thyroxin (which controls the metabolic rate) into the
bloodstream. Falling levels of thyroxin stimulate receptors in the brain to signal
the hypothalamus to release a hormone that acts on the pituitary gland to release
thyroid-stimulating hormone (TSH) into the blood. TSH acts on the thyroid,
causing it to increase production of thyroxin.

Intrinsic

Local, or intrinsic, controls usually involve only one organ or tissue. When
muscles use more oxygen, and also produce more carbon dioxide, intrinsic
controls cause dilation of the blood vessels allowing more blood into those active
areas of the muscles. Eventually the vessels will return to “normal”.

Feedback Systems in Homeostasis

NEGATIVE FEEDBACK MECHANISM

 These are used by most of the body’s systems, and are called negative
because the information caused by the feedback causes a reverse of the response.
Negative feedback mechanism consists of reducing the output or activity of any
organ or system back to its normal range of functioning.

A good example of this is regulating blood pressure. Blood vessels can

sense resistance of blood flow against the walls when blood pressure increases.
The blood vessels act as the receptors and they relay this message to the brain.
The brain then sends a message to the heart and blood vessels, both of which are
the effectors. The heart rate would decrease as the blood vessels increase in
diameter (or vasodilation). This change would cause the blood pressure to fall
back to its normal range. The opposite would happen when blood pressure
decreases, and would cause vasoconstriction.TSH is an example: blood levels of
TSH serve as feedback for production of TSH.

POSITIVE FEEDBACK MECHANISM

It is designed to accelerate or enhance the output created by a stimulus that

has already been activated. Input increases or accelerates the response. During
uterine contractions, oxytocin is produced. Oxytocin causes an increase in
frequency and strength of uterine contractions. This in turn causes further
production of oxytocin, etc. Unlike negative feedback mechanisms that initiate
to maintain or regulate physiological functions within a set and narrow range, the
positive feedback mechanisms are designed to push levels out of normal ranges

Thus, homeostasis depends on the action and interaction of a number of

body systems to maintain a range of conditions within which the body can best
operate. Homeostatic mechanisms are a fundamental characteristic of living
things. Without these mechanisms, facets of a body that need to be kept operating
in a steady state, such as temperature, salinity, acidity, hormone levels,
concentration of gases such as carbon dioxide, and the concentrations of
nutrients, would become so unbalanced as to threaten the life of the organism.

HOMEOSTATIC IMBALANCE

➢ Many diseases are a result of disturbances of homeostatic, a condition

known as Homeostatic imbalance.

➢ As it ages, every organism will lose efficiency in its control system. The
inefficiency gradually results in an unstable internal environment that
increases the risk for illness.

➢ In addition, homeostasis imbalance is also responsible for the physical

changes associated with aging.

➢ Heart failure has been seen where nominal negative feedback mechanism
become over whelmed and destructive positive mechanism take over.
 SUMMARY

Till now we have discussed regarding the pathophysiology and

psychodynamics of disease causation in the definition of health and causation of
diseases and pathogenesis of disease causation and all the theories of disease
causation, stress and their coping strategies and nurses role.
 CONCLUSION

As a part of nursing this is important to know the pathophysiology and

psychodynamics of disease causation to know the process of disease and the
pathophysiology to treat the patients accordingly, and it is important to the nurses
because they play a vital role in taking care of diseases.
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