: The practice of modern medicine

 

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: The practice of modern medicine

: The practice of modern medicine

Contens:

1. Health care and its delivery

2. ORGANIZATION OF HEALTH SERVICES

3. Levels of health care.

4. Costs of health care.

5. ADMINISTRATION OF PRIMARY HEALTH CARE

6. MEDICAL PRACTICE IN. DEVELOPED COUNTRIES

7. Britain.

8. United Stales.

9. Russia.

10. Japan.

11. Other developed countries.

12. MEDICAL PRACTICE IN DEVELOPING COUNTRIES

13. China

14. India.

15. ALTERNATIVE OR COMPLEMENTARY MEDICINE

16. SPECIAL PRACTICES AND FIELDS OF MEDICINE

17. Specialties in medicine.

18. Teaching.

19. Industrial medicine.

20. Family health care.

21. Geriatrics.

22. Public health practice.

23. Military practice.

24. CLINICAL RESEARCH

25. Historical notes.

26. Clinical observation.

27. Drug research.

28. Surgery.

29. SCREENING PROCEDURES

THE PRACTICE OF MODERN MEDICINE

Health care and its delivery

The World Health Organization at its 1978 international, conference held in

the Soviet Union produced the Alma-Ata Health Declaration, which was designed

to serve governments as a basis for planning health care that would reach

people at all levels of society. The declaration reaffirmed that "health,

which is a state of complete physical, mental and social well-being, and not

merely the absence of disease or infirmity, is a fundamental human rit.nl and

that the attainment of the highest possible level of health is a most

important world-wide social goal whose realization requires the action of

many other social and economic sectors in addition to the health sector." In

its widest form the practice of medicine, that is to say the promotion and

care of health, is concerned with this ideal.

ORGANIZATION OF HEALTH SERVICES

"It is generally the goal of most countries to have their health services

organized in such a way to ensure that individuals, families, and communities

obtain the maximum benefit from current knowledge and technology available

for the promotion, maintenance, and restoration of health. In order to play

their part in this process, governments and other agencies are faced with

numerous tasks, including the following: (1) They must obtain as much

information as is possible on the size, extent, and urgency of their needs;

without accurate information, planning can be misdirected. (2) These needs

must then be revised against the resources likely to be available in terms of

money, manpower, and materials; developing countries may well require

external aid to supplement their own resources. (3) Based on their

assessments, countries then need to determine realistic objectives and draw

up plans. (4) Finally, a process of evaluation needs to be built into the

program; the lack of reliable information and accurate assessment can lead to

confusion, waste, and inefficiency.

Health services of any nature reflect a number "I interrelated

characteristics, among which the most obvious but not necessarily the most

important from a national point of view, is the curative function; that is to

say caring for those already ill. Others include special services that deal

with particular groups (such as children or pregnant women) and with

specific needs such as nutrition or immunization; preventive services, the

protection of the health both of individuals and of communities; health

education; and, as mentioned above, the collection and analysis of

information.

Levels of health care.

In the curative domain there are various forms f medical practice. They may

be thought of generally as forming a pyramidal structure, with three tiers

representing increasing degrees of specialization and technical

sophistication but catering to diminishing numbers of patients as they are

filtered out of the system at a lower level. Only those patients who require

special attention or treatment should reach the second (advisory) or third

(specialized treatment) tiers where the cost per item of service becomes

increasingly higher. The first level represents primary health care, or first

contact care, or which patients have their initial contact with the health-

care system.

Primary health care is an integral part of a country's health maintenance

system, of which it forms the largest and most important part. As described

in the declaration of Alma-Ata, primary health care should be "based on

practical scientifically sound and socially acceptable methods and

technology made universally accessible to individuals in the community

through their full participation and at a cost that the community and country

can afford to maintain at every stage of then development." Primary health

care in the developed countries is usually the province of a medically

qualified physician; in the developing countries first contact care is often

provided by nonmedically qualified personnel.

The vast majority of patients can be fully dealt with at the primary level.

Those who cannot are referred to the second tier (secondary health care, or

the referral services) for the opinion of a consultant with specialized

knowledge or for X-ray examinations and special tests. Secondary health care

often requires the technology offered by a local or regional hospital.

Increasingly, however, the radiological and laboratory services provided by

hospitals are available directly to the family doctor, thus improving his

service to palings and increasing its range. The third tier of health care

employing specialist services, is offered by institutions such as leaching

hospitals and units devoted to the care of particular groupswomen, children,

patients with mental disorders, and so on. The dramatic differences in the

cost of treatment at the various levels is a matter of particular importance

in developing countries, where the cost of treatment for patients at the

primary health-care level is usually only a small fraction of that at the

third level- medical costs at any level in such countries, however, are

usually borne by the government.

Ideally, provision of health care at all levels will be available to all

patients; such health care may be said to be universal. The well-off, both in

relatively wealthy industrialized countries and in the poorer developing

world, may be able to get medical attention from sources they prefer and can

pay for in the private sector. The vast majority of people in most countries,

however, are dependent in various ways upon health services provided by the

state, to which they may contribute comparatively little or, in the case of

poor countries, nothing at all.

Costs of health care. The costs to national economics of providing health

care are considerable and have been growing at a rapidly increasing rate,

especially in countries such as the United States, Germany, and Sweden; the

rise in Britain has been less rapid. This trend has been the cause of major

concerns in both developed and developing countries. Some of this concern is

based upon the lack of any consistent evidence to show that more spending on

health care produces better health. There is a movement in developing countries

to replace the type of organization of health-care services that evolved during

European colonial times with some less expensive, and for them, more

appropriate, health-care system.

In the industrialized world the growing cost of health services has caused

both private and public health-care delivery systems to question current

policies and to seek more economical methods of achieving their goals.

Despite expenditures, health services are not always used effectively by

those who need them, and results can vary widely from community to community.

In Britain, for example, between 1951 and 1971 the death rate fell by 24

percent in the wealthier sections of the population but by only half that in

the most underprivileged sections of society. The achievement of good health

is reliant upon more than just the quality of health care. Health entails

such factors as good education, safe working conditions, a favourable

environment, amenities in the home, well-integrated social services, and

reasonable standards of living.

In the developing countries. The developing countries differ from one

another culturally, socially, and economically, but what they have in common

is a low average income per person, with large percentages of their

populations living at or below the poverty level. Although most have a small

elite class, living mainly in the cities, the largest part of their populations

live in rural areas. Urban regions in developing and some developed countries

in the mid- and late 20th century have developed pockets of slums, which are

growing because of an influx of rural peoples. For lack of even the simplest

measures, vast numbers of urban and rural poor die each year of preventable

and curable diseases, often associated with poor hygiene and sanitation, impure

water supplies, malnutrition, vitamin deficiencies, and chronic preventable

infections. The effect of these and other deprivations is reflected by the

finding that in the 1980s the life expectancy at birth for men and women was

about one-third less in Africa than it was in Europe; similarly, infant

mortality in Africa was about eight times greater than in Europe. The extension

of primary health-care services is therefore a high priority in the developing

countries.

The developing countries themselves, lacking the proper resources, have often

been unable to generate or implement the plans necessary to provide required

services at the village or urban poor level. It has, however, become clear

that the system of health care that is appropriate for one country is often

unsuitable for another. Research has established that effective health care

is related to the special circumstances of the individual country, its

people, culture, ideology, and economic and natural resources.

The rising costs of providing health care have influenced a trend,

especially among the developing nations to promote services that employ less

highly trained primary health-care personnel who can be distributed more

widely in order to reach the largest possible proportion of the community.

The principal medical problems to be dealt with in the developing world

include undernutrition, infection, gastrointestinal disorders, and

respiratory complaints. which themselves may be the result of poverty,

ignorance, and poor hygiene. For the most part, these are easy to identity

and to treat. Furthermore, preventive measures are usually simple and cheap.

Neither treatment nor prevention requires extensive professional training: in

most cases they can be dealt with adequately by the "primary health worker,"

a term that includes all nonprofessional health personnel.

In the developed countries. Those concerned with providing health care

in the developed countries face a different set of problems. The diseases so

prevalent in the Third World have, for the most part, been eliminated or are

readily treatable. Many of the adverse environmental conditions and public

health hazards have been conquered. Social services of varying degrees of

adequacy have been provided. Public funds can be called upon to support the

cost of medical care, and there are a variety of private insurance plans

available to the consumer. Nevertheless, the funds that a government can devote

to health care are limited and the cost of modern medicine continues to

increase thus putting adequate medical services beyond the reach of many.

Adding to the expense of modern medical practices is the increasing demand for

greater funding of health education and preventive measures specifically

directed toward the poor.

ADMINISTRATION OF PRIMARY HEALTH CARE

In many parts of the world, particularly in developing countries, people get

their primary health care, or first-contact care, where available at all,

from nonmedically qualified personnel; these cadres of medical auxiliaries

are being trained in increasing numbers to meet overwhelming needs among

rapidly growing populations. Even among the comparatively wealthy countries

of the world, containing in all a much smaller percentage of the world's

population, escalation in the costs of health services and in the cost of

training a physician has precipitated some movement toward reappraisal of the

role of the medical doctor in the delivery of first-contact care.

In advanced industrial countries, however, it is usually a trained physician

who is called upon to provide the first-contact care. The patient seeking

first-contact care can go either to a general practitioner or turn directly

to a specialist. Which is the wisest choice has become a subject of some

controversy. The general practitioner, however, is becoming rather rare in

some developed countries. In countries where he does still exist, he is being

increasingly observed as an obsolescent figure, because medicine covers an

immense, rapidly changing, and complex field of which no physician can

possibly master more than a small fraction. The very concept of the general

practitioner, it is thus argued, may be absurd.

The obvious alternative to general practice is the direct access of a patient

to a specialist. If a patient has problems with vision, he goes to an eye

specialist, and if he has a pain in his chest (which he fears is due to his

heart), he goes to a heart specialist. One objection to this plan is that the

patient often cannot know which organ is responsible for his symptoms, and

the most careful physician, after doing many investigations, may remain

uncertain as to the cause. Breathlessnessa common symptommay be due to

heart disease, to lung disease, to anemia, or to emotional upset. Another

common symptom is general malaisefeeling run-down or always tired; others

are headache, chronic low backache, rheumatism, abdominal discomfort, poor

appetite, and constipation. Some patients may also be overtly anxious or

depressed. Among the most subtle medical skills is the ability to assess

people with such symptoms and to distinguish between symptoms that are caused

predominantly by emotional upset and those that are predominantly of bodily

origin. A specialist may be capable of such a general assessment, but, often,

with emphasis on his own subject, he fails at this point. The generalist with

his broader training is often the better choice for a first diagnosis, with

referral to a specialist as the next option,

It is often felt that there are also practical advantages for the patient in

having his own doctor, who knows about his background, who has seen him

through various illnesses, and who has often looked after his family as

well. This personal physician, often a generalist, is in the best position to

decide when the patient should be referred to a consultant.

The advantages of general practice and specialization are combined when the

physician of first contact is a pediatrician. Although he sees only children

and thus acquires a special knowledge of childhood maladies, he remains a

generalist who looks at the whole patient. Another combination of general

practice and specialization is represented by group practice, the members of

which partially or fully specialize. One or more may be general

practitioners, and one may be a surgeon, a second an obstetrician, a third a

pediatrician, and a fourth an internist. In isolated communities group

practice may be a satisfactory compromise, but in urban regions, where

nearly everyone can be sent quickly to a hospital, the specialist surgeon

working in a fully equipped hospital can usually provide better treatment

than a general practitioner surgeon in a small clinic hospital.

MEDICAL PRACTICE IN. DEVELOPED COUNTRIES

Britain. Before 1948, general practitioners in Britain settled where they

could make a living. Patients fell into two main groups: weekly wage earners,

who were compulsorily insured, were on a doctor's "panel" and were given free

medical attention (for which the doctor was paid quarterly by the government);

most of the remainder paid the doctor a fee for service at the time of the

illness. In 1948 the National Health Service began operation. Under its

provisions, everyone is entitled to free medical attention with a general

practitioner with whom he is registered. Though general practitioners in the

National Health Service are not debarred from also having private patients,

these must be people who are not registered with them under the National Health

Service. Any physician is free to work as a general practitioner entirely

independent of the National Health Service, though there are few who do so.

Almost the entire population is registered with a National Health Service

general practitioner, and the vast majority automatically sees this physician,

or one of his partners, when they require medical attention. A few people,

mostly wealthy, while registered with a National Health Service general

practitioner, regularly see another physician privately; and a few may

occasionally seek a private consultation because they are dissatisfied with

their National Health Service physician.

A general practitioner under the National Health Service remains an

independent contractor, paid by a capitation fee; that is, according to the

number of people registered with him. He may work entirely from his own

office, and he provides and pays his own receptionist, secretary, and other

ancillary staff. Most general practitioners have one or more partners and

work more and more in premises built for the purpose. Some of these

structures are erected by the physicians themselves, but many are provided by

the local 'authority, me physicians paying rent for using them. Health

centres, in which groups of general practitioners work have become common.

In Britain only a small minority of general practitioners can admit patients

to a hospital and look after them personally. Most of this minority are in

country districts, where, before the days of the National Health Service,

there were cottage hospitals run by general practitioners; many of these

hospitals continued to function in a similar manner. All general

practitioners use such hospital facilities as X-ray departments and

laboratories, and many general practitioners work in hospitals in emergency

rooms (casualty departments) or as clinical assistants to consultants, or

specialists.

General practitioners are spread more evenly over the country than formerly,

when there were many in the richer areas and few in the industrial towns. The

maximum allowed list of National Health Service patients per doctor is

3.500; the average is about 2.500. Patients have free choice of the physician

with whom they register, with the proviso that they cannot be accepted by one

who already has a full list and that a physician can refuse to accept them

(though such refusals are rare). In remote rural places there may be only one

physician within a reasonable distance.

Until the mid-20th century it was not unusual for the doctor in Britain to

visit patients in their own homes. A general practitioner might make 15 or 20

such house calls in a day. as well as seeing patients in his office or

"surgery," often in the evenings. This enabled him to become a family doctor

in fact as well as in name. In modern practice, however, a home visit is

quite exceptional and is paid only to the severely disabled or seriously ill

when other recourses are ruled out. All patients are normally required to go

to the doctor.

It has also become unusual for a personal doctor to be available during

weekends or holidays. His place may be taken by one of his partners in a

group practice, a provision that is reasonably satisfactory. General

practitioners, however, may now use one of several commercial deputizing

services that employs young doctors to he on call. Although some of these

young doctors may he well experienced, patients do not generally appreciate

this kind of arrangement.

United Stales. Whereas in Britain the doctor of first contact is

regularly a general practitioner, in the United States the nature of

first-contact care is less consistent. General practice in the United States

has been in a slate of decline in the second half of the 20th century

especially in metropolitan areas. The general practitioner, however, is being

replaced to some degree by the growing field of family practice. In 1969 family

practice was recognized as a medical specialty after the American Academy of

General Practice (now the American Academy of Family Physicians) and the

American Medical Association created the American Board of General (now Family)

Practice. Since that time the field has become one of the larger medical

specialties in the United States. The family physicians were the first group of

medical specialists in the

United States for whom recertification was required.

Theie is no national health service, as such, in the United Stales. Most

physicians in the country have traditionally been in some form of private

practice, whether seeing patients in their own offices. clinics, medical

centres, or another type of facility and regardless of the patients' income.

Doctors are usually compensated by such state and federally supported

agencies as Medicaid (for treating the poor) and Medicare (for treating the

elderly); not all doctors, however, accept poor patients. There are also

some state-supported clinics and hospitals where the poor and elderly may

receive free or low-cost treatment, and some doctors devote a small

percentage of their time to treatment of the indigent. Veterans may receive

free treatment at Veterans Administration hospitals, and the federal

government through its Indian Health Service provides medical services to

American Indians and Alaskan natives, sometimes using trained auxiliaries for

first-contact care.

In the rural United States first-contact care is likely to come from a

generalist I he middle- and upper-income groups living in urban areas,

however, have access to a larger number of primary medical care options.

Children are often taken to pediatricians, who may oversee the child's health

needs until adulthood. Adults frequently make their initial contact with an

internist, whose field is mainly that of medical (as opposed to surgical)

illnesses; the internist often becomes the family physician. Other adults

choose to go directly to physicians with narrower specialties, including

dermatologists, allergists, gynecologists, orthopedists, and

ophthalmologists.

Patients in the United States may also choose to be treated by doctors of

osteopathy. These doctors are fully qualified, but they make up only a small

percentage of the country's physicians. They may also branch off into

specialties, hut general practice is much more common in their group than

among M.D.'s.

It used to be more common in the United States for physicians providing

primary care to work independently, providing their own equipment and paying

their own ancillary staff. In smaller cities they mostly had full hospital

privileges, but in larger cities these privileges were more likely to be

restricted. Physicians, often sharing the same specialties, are increasingly

entering into group associations, where the expenses of office space, staff,

and equipment may be shared; such associations may work out of suites of

offices, clinics, or medical centres. The increasing competition and risks of

private practice have caused many physicians to join Health Maintenance

Organizations (HMOs), which provide comprehensive medical. care and hospital

care on a prepaid basis. Th cost savings to patient's are considerable, but

they must use only the HMO doctors and facilities. HMOs stress preventive

medicine and out-patient treatment as opposed to hospitalization as a means

of reducing costs, a policy that has caused an increased number of empty

hospital beds in the United States.

While the number of doctors per 100,000 population in the United States has

been steadily increasing, there has been a trend among physicians toward the

use of trained medical personnel to handle some of the basic services

normally performed by the doctor. So-called physician extender services are

commonly divided into nurse practitioners and physician's assistants, both

of whom provide similar ancillary services for the general practitioner or

specialist. Such personnel do not replace the doctor. Almost all American

physicians have systems for taking each other's calls when they become

unavailable. House calls in the United Stales, as in Britain, have become

exceedingly rare.

Russia. In Russia general practitioners are prevalent in the thinly

populated rural areas. Pediatricians deal with children up to about age 15.

Internists look after the medical ills of adults, and occupational physicians

deal with the workers, sharing care with internists.

Teams of physicians with experience in varying specialties work from

polyclinics or outpatient units, where many types of diseases are treated.

Small towns usually have one polyclinic to serve all purposes. Large cities

commonly have separate polyclinics for children and adults, as well as

clinics with specializations such as women's health care, mental illnesses,

and sexually transmitted diseases. Polyclinics usually have X-ray apparatus

and facilities for examination of tissue specimens, facilities associated

with the departments of the district hospital. Beginning in the late 1970s

was a trend toward the development of more large, multipurpose treatment

centres, first-aid hospitals, and specialized medicine and health care

centres.

Home visits have traditionally been common, and much of the physician's time

is spent in performing routine checkups for preventive purposes. Some

patients in sparsely populated rural areas may be seen first by feldshers

(auxiliary health workers), nurses, or midwives who work under the

supervision of a polyclinic or hospital physician. The feldsher was once a

lower-grade physician in the army or peasant communities, but feldshers are

now regarded as paramedical workers.

Japan. In Japan, with less rigid legal restriction of the sale of

pharmaceuticals than in the West, there was formerly a strong tradition of

self-medication and self-treatment. This was modified in 1961 by the

institution of health insurance programs that covered a large proportion of the

population; there was then a great increase in visits to the outpatient clinics

of hospitals and to private clinics and individual physicians.

When Japan shifted from traditional Chinese medicine with the adoption of

Western medical practices in the 1870s. Germany became the chief model. As a

result of German influence and of their own traditions, Japanese physicians

tended to prefer professorial status and scholarly research opportunities at

the universities or positions in the national or prefectural hospitals to

private practice. There were some pioneering physicians, however, who brought

medical care to the ordinary people.

Physicians in Japan have tended to cluster in the urban areas. The Medical

Service Law of 1963 was amended to empower the Ministry of Health and Welfare

to control the planning and distribution of future public and nonprofit

medical facilities, partly to redress the urban-rural imbalance. Meanwhile,

mobile services were expanded.

The influx of patients into hospitals and private clinics after the passage

of the national health insurance acts of 1961 had, as one effect, a severe

reduction in the amount of time available for any one patient. Perhaps in

reaction to this situation, there has been a modest resurgence in the

popularity of traditional Chinese medicine, with its leisurely interview, its

dependence on herbal and other "natural" medicines, and its other traditional

diagnostic and therapeutic practices. The rapid aging of the Japanese

population as a result of the sharply decreasing death rate and birth rate

has created an urgent need for expanded health care services /or the elderly.

There has also been an increasing need for centres to treat health problems

resulting from environmental causes.

Other developed countries. On the continent of Europe there are great

differences both within single countries and between countries in the kinds of

first-contact medical care. General practice, while declining in Europe as

elsewhere, is still rather common even in some large cities, as well as in

remote country areas.

In The Netherlands, departments of general practice are administered by

general practitioners in all the medical schoolsan exceptional state of

affairsand general practice flourishes. In the larger cities of Denmark,

general practice on an individual basis is usual and popular, because the

physician works only during office hours. In addition, there is a duty doctor

service for nights and weekends. In the cities of Sweden, primary care is

given by specialists. In the remote regions of northern Sweden, district

doctors act as general practitioners to patients spread over huge areas; the

district doctors delegate much of their home visiting to nurses.

In France there are still general practitioners, but their number is

declining. Many medical practitioners advertise themselves directly to the

public as specialists in internal medicine, ophthalmologists, gynecologists,

and other kinds of specialists. Even when patients have a general

practitioner, they may still go directly to a specialist. Attempts to stem

the decline in general practice are being made hy the development of group

practice and of small rural hospitals equipped to deal with less serious

illnesses, where general practitioners can look after their patients.

Although Israel has a high ratio of physicians to population, there is a

shortage of general practitioners, and only in rural areas is general

practice common. In the towns many people go directly to pediatricians,

gynecologists, and other specialists, but there has been a reaction against

this direct access to the specialist. More general practitioners have been

trained, and the Israel Medical Association has recommended that no patient

should be referred to a specialist except by the family physician or on

instructions given by the family nurse. At Tel Aviv University there is a

department of family medicine. In some newly developing areas, where the

doctor shortage is greatest, there are medical centres at which all patients

are initially interviewed by a nurse. The nurse may deal with many minor

ailments, thus freeing the physician to treat the more seriously ill.

Nearly half the medical doctors in Australia are general practitionersa far

higher proportion than in most other advanced countriesthough, as elsewhere,

their numbers are declining. They tend to do far more for their patients than

in Britain, many performing such operations as removal of the appendix,

gallbladder, or uterus, operations that elsewhere would be carried out by a

specialist surgeon. Group practices are common.

MEDICAL PRACTICE IN DEVELOPING COUNTRIES

China. Health services in China since the Cultural Revolution have been

characterized by decentralization and dependence on personnel chosen locally

and trained for short periods. Emphasis is given to selfless motivation,

self-reliance, and to the involvement of everyone in the community. Campaigns

stressing the importance of preventive measures and their implementation have

served to create new social attitudes as well as to break down divisions

between different categories of health workers. Health care is regarded as a

local matter that should not require the intervention of any higher authority;

it is based upon a highly organized and well-disciplined system that is

egalitarian rather than hierarchical, as in Western societies, and which is

well suited to the rural areas where about two-thirds of the population live.

In the large and crowded cities an important constituent of the health-care

system is the residents' committees, each for a population of 1,000 to 5,000

people. Care is provided by part-time personnel with periodic visits by a

doctor. A number of residents' committees are grouped together into

neighbourhoods of some 50,000 people where there are clinics and general

hospitals staffed by doctors as well as health auxiliaries trained in both

traditional and Westernized medicine. Specialized care is provided at the

district level (over 100,000 people), in district hospitals and in epidemic and

preventive medicine centres. In many rural districts people's communes have

organized cooperative medical services that provide primary care for a small

annual fee.

Throughout China the value of traditional medicine is stressed, especially in

the rural areas. All medical schools are encouraged to teach traditional

medicine as part of their curriculum, and efforts are made to link colleges

of Chinese medicine with Western-type medical schools. Medical education is

of shorter duration than it is in Europe, and there is greater emphasis on

practical work. Students spend part of their time away from the medical

school working in factories or in communes; they are encouraged to question

what they are taught and to participate in the educational process at all

stages. One well-known form of traditional medicine is acupuncture, which is

used as a therapeutic and pain-relieving technique; requiring the insertion

of brass-handled needles at various points on the body, acupuncture has

become quite prominent as a form of anesthesia.

The vast number of nonmedically qualified health staff, upon whom the health-

care system greatly depends, includes both full-time and part-time workers.

The latter include so-called barefoot doctors, who work mainly in rural

areas, worker doctors in factories, and medical workers in residential

communities. None of these groups is medically qualified. They have had only

a three-month period of formal training, part of which is done in a

hospital, fairly evenly divided between theoretical and practical work. This

is followed by a varying period of on-the-job experience under supervision.

India. Ayurvedic medicine is an example of a well-organized system of

traditional health care, both preventive and curative, that is widely

practiced in parts of Asia. Ayurvedic medicine has a long tradition behind it,

having originated in India perhaps as long as 3.000 years ago. It is still a

favoured form of health care in large parts of the Eastern world, especially in

India, where a large percentage of the population use this system exclusively

or combined with modern medicine. The Indian Medical Council was set up in 1971

by the Indian government to establish maintenance of standards for

undergraduate and postgraduate education. It establishes suitable

qualifications in Indian medicine and recognizes various forms of traditional

practice including Ayurvedic. Unani. and Siddha. Projects have been undertaken

to integrate the indigenous Indian and Western forms of medicine. Most

Ayurvedic practitioners work in rural areas, providing health care to at least

500,000.000 people in India alone. They therefore represent a major force for

primary health care, and their training and deployment are important to the

government of India.

Like scientific medicine, Ayurvedic medicine has both preventive and curative

aspects. The preventive component emphasizes the need for a strict code of

personal and social hygiene, the details of which depend upon individual,

climatic, and environmental needs. Rodilv exercises, the use of herbal

preparations, and Yoga form a part of the remedial measures. The curative

aspects of Avurvcdic medicine involves the use of herbal medicines, 'external

preparations, physiotherapy, and diet. It is a principle of Ayurvedic

medicini. that the preventive and therapeutic measures be adapted to the

personal requirements of each patient.

Other developing countries. A main goal of the World Health Organization

(WHO), as expressed in the Alma-Ata Declaration of 1978, is to provide to all

the citizens of the world a level of health that will allow them to lead

socially and economically productive lives by the year 2000. By the late

1980s, however, vast disparities in health care still existed between the

rich and poor countries of the world. In developing countries such as

Ethiopia, Guinea, Mali, and Mozambique, for instance, governments in the late

1980s spent less than $5 per person per year on public health, while in most

western European countries several hundred dollars per year was spent on each

person. The disproportion of the number of physicians available between

developing and developed countries is similarly wide.

Along with the shortage of physicians, there is a shortage of everything

else needed to provide medical careof equipment, drugs, and suitable

buildings, and of nurses, technicians, and all other grades of staff, whose

presence is taken for granted in the affluent societies. Yet there are

greater percentages of sick in the poor countries than in the rich countries.

In the poor countries a high proportion of people are young, and all are

liable to many infections, including tuberculosis, syphilis, typhon). and

cholera (which, with the possible exception of syphilis, are now rare in the

rich countries), and also malaria, yaws. worm infestations, and many other

conditions occurring primarily in the warmer climates. Nearly all of these

infections respond to the antibiotics and other drugs that have been

discovered since the 1920s. There is also much malnutrition and anemia, which

can be cured if funding is available. There is a prevalence of disorders

remediable by surgery. Preventive medicine can ensure clean water supplies,

destroy insects that carry infections, teach hygiene, and show how to make

the best use of resources.

In most poor countries there are a few people, usually living in the cities,

who can afford to pay for medical care and in a free market system the

physicians lend to go where they can make the best living; this situation

causes the doctor-patient ratio to be much higher in the towns than in

country districts. A physician in Bombay or in Rio de Janeiro, for example,

may have equipment as lavish as that of a physician in the United States and

can earn an excellent income. The poor, however, both in the cities and in

the country, can gel medical attention only if it is paid for by the state,

by some supranational body, or by a mission or other charitable organization.

Moreover, the quality of the care they receive is often poor, and in remote

regions it may be lacking altogether. In practice, hospitals run by a mission

may cooperate closely with stale-run health centres.

Because physicians are scarce, their skills must be used to best advantage,

and much of the work normally done by physicians in the rich countries has to

be delegated to auxiliaries or nurses, who have to diagnose the common

conditions, give treatment, take blood samples, help with operations, supply

simple posters containing health advice, and carry out other tasks. In such

places the doctor has lime only to perform major operations and deal with the

more difficult medical problems. People are treated as far as possible on an

outpatient basis from health centres housed in simple buildings; few can

travel except on foot, and, if they are more than a few miles from a health

centre, they tend not to go there. Health centres also may be used for health

education.

Although primary health-care service diners from country to country, that

developed in Tanzania is representative of many that have been devised in

largely rural developing countries. The most important feature of the

Tanzanian rural health service is the rural health centre, which, with its

related dispensaries, is intended to provide comprehensive health services

for the community. The staff is headed by the assistant medical officer and

the medical assistant. The assistant medical officer has at least lour years

of experience, which is then followed by further training for 18 months. He

is not a doctor but serves to bridge the gap between medical assistant and

physician. The medical assistant has three years of general medical

education. The work of the rural health centres and dispensaries is mainly of

three kinds: diagnosis and treatment, maternal and child health, and

environmental health. The main categories of primary health workers also

include medical aids, maternal and child health aids, and health auxiliaries.

Nurses and midwives form another category of worker. In the villages there

are village health posts staffed by village medical helpers working under

supervision from the rural health centre.

In some primitive elements of the societies of developing countries, and of

some developed countries, there exists the belief that illness comes from the

displeasure of ancestral gods and evil spirits, from the malign influence of

evil disposed persons, or from natural phenomena that can neither he forecast

nor controlled. To deal with such causes there are many varieties of

indigenous healers who practice elaborate rituals on behalf of both the

physically ill and the mentally afflicled. If it is understood that such

beliefs, and other forms of shamanism, may provide a basis upon which health

care can be based, then primary health care may he said to exist almost

everywhere. It is not only easily available but also readily acceptable, and

often preferred, to more rational methods of diagnosis and treatment.

Although such methods may sometimes be harmful, they may often be effective,

especially where the cause is psychosomatic. Other patients, however, may

suffer from a disease for which there is a cure in modern medicine.

In order to improve the coverage of primary health-care services and lo spread

more widely some of the benefits of Wesiern medicine, attempts have sometimes

been made to tun.) a means of cooperation, or even integration, between

traditional and modern medicine (see above India). In Aluca, for

example, some such attempts are officially sponsored by ministries of health,

state governments, universities, and the like, and they have the approval of

WHO, which often lakes the lead in this activity. In view, however, of the

historical relationships between these two systems of medicine, their different

basic concepts, and the fuel that their methods cannot readily be combined,

successful merging has been limited.

ALTERNATIVE OR COMPLEMENTARY MEDICINE

Persons dissatisfied with the methods of modern medicine or with its results

sometimes seek help from those professing expertise in other, less

conventional, and sometimes controversial, forms of health care. Such

practitioners are not medically qualified unless they are combining such

treatments with a regular (allopathic) practice, which includes osteopathy.

In many countries the use of some forms, such as chiropractic, requires

licensing and a degree from an approved college. The treatments afforded in

these various practices are not always subjected to objective assessment, yet

they provide services that are alternative, and sometimes complementary, to

conventional practice. This group includes practitioners of homeopathy,

naturopathy, acupuncture, hypnotism, and various meditative and quasi-

religious forms. Numerous persons also seek out some form of faith healing to

cure their ills, sometimes as a means of last resort. Religions commonly

include some advents of miraculous curing within their scriptures. The belief

in such curative powers has been in part responsible for the increasing

popularity of the television, or "electronic," preacher in the United States,

a phenomenon that involves millions of viewers. Millions of others annually

visit religious shrines, such as the one at Lourdes in France, with the hope

of being miraculously healed.

SPECIAL PRACTICES AND FIELDS OF MEDICINE

Specialties in medicine. At the beginning of World War II it was possible

to recognize a number of major medical specialties, including internal

medicine, obstetrics and gynecology, pediatrics, pathology, anesthesiology,

ophthalmology, surgery, orthopedic surgery, plastic surgery, psychiatry and

neurology, radiology, and urology. Hematology was also an important field of

study, and microbiology and biochemistry were important medically allied

specialties. Since World War II, however, there has been an almost explosive

increase of knowledge in the medical sciences as well as enormous advances in

technology as applicable to medicine. These developments have led to more and

more specialization. The knowledge of pathology has been greatly extended,

mainly by the use of the electron microscope; similarly microbiology, which

includes bacteriology, expanded with the growth of such other subfields as

virology (the study of viruses) and mycology (the study of yeasts and fungi in

medicine). Biochemistry, sometimes called clinical chemistry or chemical

pathology, has contributed to the knowledge of disease, especially in the

field of genetics where genetic engineering has become a key to curing some of

the most difficult diseases. Hematology also expanded after World War II with

the development of electron microscopy. Contributions to medicine have come

from such fields as psychology and sociology especially in such areas as

mental disorders and mental handicaps. Clinical pharmacology has led to the

development of more effective drugs and to the identification of adverse

reactions. More recently established medical specialties are those of

preventive medicine, physical medicine and rehabilitation, family practice,

and nuclear medicine. In the United States every medical specialist must be

certified by a board composed of members of the specialty in which

certification is sought. Some type of peer certification is required in most

countries.

Expansion of knowledge both in depth and in range has encouraged the

development of new forms of treatment that require high degrees of

specialization, such as organ transplantation and exchange transfusion; the

field of anesthesiology has grown increasingly complex as equipment and

anesthetics have improved. New technologies have introduced microsurgery,

laser beam surgery, and lens implantation (for cataract patients), all

requiring the specialist's skill. Precision in diagnosis has markedly

improved; advances in radiology, the use of ultrasound, computerized axial

tomography (CAT scan), and nuclear magnetic resonance imaging are examples of

the extension of technology requiring expertise in the field of medicine.

To provide more efficient service it is not uncommon for a specialist surgeon

and a specialist physician to form a team working together in the field of,

for example, heart disease. An advantage of this arrangement is that they can

attract a highly trained group of nurses, technologists. operating room

technicians, and so on, thus greatly improving the efficiency of the service

to the patient. Such specialization is expensive, however, and has required

an increasingly large proportion of the health budget of institutions, a

situation that eventually has its financial effect on the individual citizen.

The question therefore arises as to their cost-effectiveness. Governments of

developing countries have usually found, for instance, that it is more cost-

efficient to provide more people with basic care.

Teaching. Physicians in developed countries frequently prefer posts in

hospitals with medical schools. Newly qualified physicians want to work there

because doing so will aid their future careers, though the actual experience

may be wider and better in a hospital without a medical school. Senior

physicians seek careers in hospitals with medical schools because consultant,

specialist, or professorial posts there usually carry a high degree of

prestige. When the posts are salaried, the salaries are sometimes, but not

always, higher than in a nonteaching hospital. Usually a consultant who works

in private practice earns more when on the staff of a medical school.

In many medical schools there are clinical professors in each of the major

specialtiessuch as surgery, internal medicine, obstetrics and gynecology and

psychiatryand often of the smaller specialties as well. There are also

professors of pathology, radiology, and radiotherapy. Whether professors or

not, all doctors in teaching hospitals have the two functions of caring for

the sick and educating students. They give lectures and seminars and are

accompanied by students on ward rounds.

Industrial medicine. The Industrial Revolution greatly changed, and as a

rule worsened, the health hazards caused by industry, while the numbers at risk

vastly increased. In Britain the first small beginnings of efforts to

ameliorate the lot of the workers in factories and mines began in 1802 with the

passing of the first factory act, the Health and Morals of Apprentices Act. The

factory act of 1838, however, was the first truly effective measure in the

industrial field. It forbade night work for children and restricted their work

hours to 12 per day. Children under 13 were required to attend School. A

factory inspectorate was established, the inspectors being given powers of

entry into factories and power of prosecution of recalcitrant owners.

Thereafter there was a succession of acts with detailed regulations for safety

and health in all industries. Industrial diseases were made notifiable, and

those who developed any prescribed industrial disease were entitled to

benefits.

The situation is similar in other developed countries. Physicians are bound

by legal restrictions and must report industrial diseases. The industrial

physician's most important function, however, is to prevent industrial

diseases. Many of the measures to this end have become standard practice,

but, especially in industries working with new substances, the physician

should determine if workers are being damaged and suggest preventive

measures. The industrial physician may advise management about industrial

hygiene and the need for safety devices and protective clothing and may

become involved in building design. The physician or health worker may also

inform the worker of occupational health hazards.

Modern factories usually have arrangements for giving first aid in case of

accidents. Depending upon the size of the plant, the facilities may range

from a simple first-aid station to a large suite of lavishly equipped rooms

and may include a staff of qualified nurses and physiotherapists and one or

perhaps more full-time physicians.

Periodic medical examination. Physicians in industry carry out medical

examinations, especially on new employees and on those returning to work after

sickness or injury. In addition, those liable to health hazards may be examined

regularly in the hope of detecting evidence of incipient damage. In some

organizations every employee may be offered a regular medical examination.

The industrial and the personal physician. When a worker also has a

persona! physician, there may be doubt. in some cases, as to which physician

bears the main responsibility for his health. When someone has an accident

or becomes acutely ill at work, the first aid is given or directed by the

industrial physician. Subsequent treatment may be given either at the clinic

at work or by the personal physician. Because of labour-management

difficulties, workers sometimes tend not to trust the diagnosis of the

management-hired physician.

Industrial health services. During the epoch of the Soviet Union and

the Soviet bloc. industrial health service generally developed more fully in

those countries than in the capitalist countries. At the larger industrial

establishments in the Soviet Union, polyclinics were created to provide both

occupational and general can for workers and their families. Occupational

physicians were responsible for preventing occupational diseases and injuries,

health screening, immunization and health education.

In the capitalist countries, on the other hand, no fixed pattern of

industrial health service has emerged. Legislation impinges upon health in

various ways, including the provision of safety measures, the restriction of

pollution and the enforcement of minimum standards of lightning, ventilation,

and space per person. In most of these countries there is found an infinite

variety of schemes financed and run by individual firms or equally, by huge

industries. Labour unions have also done much to enforce health codes within

their respective industries. In the developing countries there has been

generally little advance in industrial medicine.

Family health care. In many societies special facilities are provided for

the health care of pregnant women mothers, and their young children. The health

care needs of these three groups, are generally recognized to be so closely

related as to require a highly integrated service that includes prenatal care,

the birth of the baby. the postnatal period, and the needs of the infant. Such

a continuum should be followed by a service attentive to the needs of young

children and then by a school health service. Family clinics are common in

countries that have state-sponsored health services, such as those in the

United Kingdom and elsewhere in Europe. Family health care in some developed

countries, such as the United States, is provided for low-income groups by

state-subsidized facilities, but other groups defer to private physicians or

privately run clinics.

Prenatal clinics provide a number of elements. There is first, the care of

the pregnant woman, especially if she is in a vulnerable group likely to

develop some complication during the last few weeks of pregnancy and

subsequent delivery. Many potential hazards, such as diabetes and high blood

pressure, can be identified and measures taken to minimize their effects. In

developing countries pregnant women are especially susceptible to many kinds

of disorders, particularly infections such as malaria. Local conditions

determine what special precautions should he taken to ensure a healthy child.

Most pregnant women, in their concern to have a healthy child, are receptive

to simple health education. The prenatal clinic provides an excellent

opportunity to teach the mother how to look after herself during pregnancy,

what to expect at delivery, and how to care for her baby. If the clinic is

attended regularly, the woman's record will he available to the staff that

will later supervise the delivery of the baby: this is particularly important

for someone who has been determined to be at risk. The same clinical unit

should he responsible for prenatal, natal, and postnatal care as well as for

the care of the newborn infants.

Most pregnant women can he safely delivered in simple circumstances without

an elaborately trained staff or sophisticated technical facilities, provided

that these can be called upon in emergencies. In developed countries it was

customary in premodern times for the delivery to take place in the woman's

home supervised by a qualified midwife or by the family doctor. By the mid-

20th century women, especially in urban areas, usually preferred to have

their babies in a hospital, either in a general hospital or in a more

specialized maternity hospital. In many developing countries traditional

birth attendants supervise the delivery. They are women, for the most part

without formal training, who have acquired skill by working with others and

from their own experience. Normally they belong to the local community where

they have the confidence of

the family, where they are content to live and serve, and where their

services are of great value. In many developing countries the better training

of him attendants has a high priority. In developed Western countries there

has been a trend toward delivery by natural childbirth, including delivery

in a hospital without anesthesia, and home delivery.

Postnatal care services are designed to supervise the return to normal of the

mother. They are usually given by the staff of the same unit that was

responsible for the delivery. Important considerations are the mailer of

breast- or artificial feeding and the care of the infant. Today the prospects

for survival of babies born prematurely or after a difficult and complicated

labour, as well as for neonates (recently born babies) with some physical

abnormality, are vastly improved. This is due to technical advances,

including those that can determine defects in the prenatal stage, as well as

to the growth of neonatology as a specialty. A vital part of the family

health-care service is the child welfare clinic, which undertakes the care of

the newbom. The first step is the thorough physical examination of the child

on one or more occasions to determine whether or not it is normal both

physically and, if possible, mentally. Later periodic examinations serve to

decide if the infant is growing satisfactorily. Arrangements can be made for

the child to be protected from major hazards by, for example, immunization

and dietary supplements. Any intercurrent condition, such as a chest

infection or skin disorder, can be detected early and treated. Throughout the

whole of this period mother and child are together, and particular attention

is paid to the education of the mother for the care of the child.

A pan of the health service available to children in the developed countries

is that devoted to child guidance. This provides psychiatric guidance to

maladjusted children usually through the cooperative work of a child

psychiatrist, educational psychologist, and schoolteacher.

Geriatrics. Since the mid-20th century a change has occurred in the

population structure in developed countries. The proportion of elderly people

has been increasing. Since 1983, however, in most European countries the

population growth of that group has leveled off, although it is expected to

continue to grow more, rapidly than the rest of the population in most

countries through the first third of the 21st century. In the late 20fti

century Japan had the fastest growing elderly population.

Geriatrics, the health care of the elderly, is therefore a considerable

burden on health services. In the United Kingdom about one-third of all

hospital beds are occupied by patients over 65; half of these are psychiatric

patients. The physician's time is being spent more and more with the elderly,

and since statistics show that women live longer than men, geriatric practice

is becoming increasingly concerned with the treatment of women. Elderly

people often have more than one disorder, many of which are chronic and

incurable, and they need more attention from health-care services. In the

United States there has been some movement toward making geriatrics a medical

specialty, but it has not generally been recognized.

Support services for the elderly provided by private or state-subsidized

sources include domestic help, delivery of meals, day-care centres, elderly

residential homes or nursing homes, and hospital beds either in general

medical wards or in specialized geriatric units. The degree of

accessibility" of these services is uneven from country to country and

within countries. In the United States, for instance, although there are some

federal programs, each state has its own elderly programs, which vary widely.

However, as the elderly become an increasingly larger part of the population

their voting rights are providing increased leverage for obtaining more

federal and state benefits. The general practitioner or family physician

working with visiting health and social workers and in conjunction with the

patient's family often form a working team for elderly care.

In the developing world, countries are largely spared such geriatric problems,

but not necessarily for positive reasons. A principal cause, for instance, is

that people do not live so long. Another major reason is that in the

extended family concept, still prevalent among developing countries, most of

the caretaking needs of the elderly are provided by the family.

Public health practice. The physician working in the field of public

health is mainly concerned with the environmental causes of ill health and in

their prevention. Bad drainage, polluted water and atmosphere, noise and

smells, infected food had housing, and poverty in general are all his special

concern. Perhaps the most descriptive title he can he given is that of

community physician. In Britain he has been customarily known as the medical

officer of health and. in the United Slates, as the health officer.

The spectacular improvement in the expectation of life in the affluent

countries has been due far more to public health measures than to curative

medicine. These public health measures began operation largely in the 19lh

century. At the beginning of that century, drainage and water supply systems

were all more or less primitive; nearly all the cities of that time had

poorer water and drainage systems than Rome had possessed 1,800 years

previously. Infected water supplies caused outbreaks of typhoid, cholera,

and other waterborne infections. By the end of the century, at least in the

larger cities, water supplies were usually safe. Food-home infections were

also drastically reduced by the enforcement of laws concerned with the

preparation, storage, and distribution of food. Insect-borne infections, such

as malaria and yellow fever, which were common in tropical and semitropical

climates, were eliminated by the destruction of the responsible insects.

Fundamental to this improvement in health has been the diminution of poverty,

for most public health measures are expensive. The peoples of the developing

countries fall sick and sometimes die from infections that are virtually

unknown in affluent countries.

Britain. Public health services in Britain are organized locally under

the National Health Service. The medical officer of health is employed by the

local council and is the adviser in health matters. The larger councils employ

a number of mostly full-time medical officers; in some rural areas, a general

practitioner may be employed part-time as medical officer of health:

The medical officer has various statutory powers conferred by acts of

Parliament, regulations and orders, such as food and drugs acts, milk and

dairies regulations, and factories acts. He supervises the work of sanitary

inspectors in the control of health nuisances. The compulsorily notifiable

infectious diseases are reported to him, and he takes appropriate action.

Other concerns of the medical officer include those involved with the work of

the district nurse, who carries out nursing duties in the home, and the

health visitor, who gives advice on health matters, especially to the

mothers of small babies. He has other duties in connection with infant

welfare clinics, creches, day and residential nurseries, the examination of

schoolchildren, child guidance clinics, foster homes, factories, problem

families, and the care of the aged and the handicapped.

United States. Federal, state, county, and city governments all have

public health futtctions. Under the U.S. Department of Health end Human

Services is the Public Health Service, headed by an assistant secretary for

health and the surgeon general. State health departments are headed by a

commissioner of health, usually a physician, who is often in the governor's

cabinet. He usually has a board of health that adopts health regulations and

holds hearings on their alleged violations. A state's public health code is the

foundation on which all county and city health regulations must be based. A

city health department may be independent of its surrounding county health

department, or there may be a combined city-county health department. The

physicians of the local health departments are usually called health officers,

though occasionally people with this title are not physicians. The larger

departments may have a public health director, a district health director, or a

regional health director.

The minimal complement of a local health department is a health officer, a

public health nurse, a sanitation expert, and a clerk who is also a

registrar of vital statistics. There may also be sanitation personnel,

nutritionists, social workers, laboratory technicians, and others.

Japan. Japan's Ministry of Health and Welfare directs public health

programs at the national level, maintaining close coordination among the

fields of preventive medicine, medical care, and welfare and health insurance.

The departments of health of the prefectures and of the largest municipalities

operate health centres. The integrated community health programs of the centres

encompass maternal and child health, communicable-disease control, health

education, family planning, health statistics, food inspection, and

environmental sanitation. Private physicians, through their local medical

associations, help to formulate and execute particular public health programs

needed by their localities.

Numerous laws are administered through the ministry's bureaus and agencies,

which range from public health, environmental sanitation, and medical

affairs to the children and families bureau. The various categories of

institutions run by the ministry, in addition to the national hospitals,

include research centres for cancer and leprosy, homes for the blind,

rehabilitation centres, for the physically handicapped, and port quarantine

services.

Former Soviet Union. In the aftermath of the dissolution of the Soviet

Union, responsibility for public health fell to the governments of the

successor countries.

The public health services for the U.S.S.R. as a whole were directed by the

Ministry of Health. The ministry, through the 15 union republic ministries of

health, directed all medical institutions within its competence as well as

the public health authorities; and services throughout the country.

The administration was centralized, with little local autonomy. Each of the 15

republics had its own ministry of health, which was responsible for carrying

out the plans and decisions established by the U.S.S.R. Ministry of Health.

Each republic was divided into oblasti, or provinces, which had

departments of health directly responsible to the republic ministry of health.

Each oblast, in turn, had rayony (municipalities), which have

their own health departments accountable to the oblast health

department. Finally, each rayon was subdivided into smaller

uchastoki (districts).

In most rural rayony the responsibility for public health lay with the

chief physician, who was also medical director of the central rayon

hospital. This system ensured unity of public health administration and

implementation of the principle of planned development. Other health personnel

included nurses, feldshers, and midwives.

For more information on the history, organization, and progress of public

health, see below.

Military practice. The medical services of armies, navies, and air forces

are geared to war. During campaigns the first requirement is the prevention of

sickness. In all wars before the 20th century, many more combatants died of

disease than of wounds. And even in World War II and wars thereafter, although

few died of disease, vast numbers became casualties from disease.

The main means of preventing sickness are the provision of adequate food and

pure water, thus eliminating starvation, avitaminosis, and dysentery and

other bowel infections, which used to be particular scourges of armies; the

provision of proper clothing and other means of protection from the weather;

the elimination from the service of those likely to fall sick: the use of

vaccination and suppressive drugs to prevent various infections, such as

typhoid and malaria; and education in hygiene and in the prevention of

sexually transmitted diseases, a particular problem in the services. In

addition, the maintenance of high morale has a sinking effect on casualty

rates, for, when morale is poor, soldiers are likely to suffer psychiatric

breakdowns, and malingering is more prevalent.

The medical branch may provide advice about disease prevention, but the

actual execution of this advice is through the ordinary chains of command. It

is the duty of the military, not of the medical, officer to ensure that the

troops obey orders not to drink infected water and to take tablets to

suppress malaria.

Army medical organisation. The medical doctor of first contact to the

soldier in the armies of developed countries is usually an officer in the

medical corps. In the doctor sees the sick and has functions similar

to those of the general practitioner, prescribing drugs and dressings and there

may be a sick bay where slightly sick soldiers can remain for a few days. The

doctor is usually assisted by trained nurses and corpsmen. If a further medical

opinion is required, the patient can be referred to a specialist at a military

or civilian hospital.

In a war zone, medical officers have an aid post where, with the help of

corpsmen, they apply first aid to the walking wounded and to the more

seriously wounded who are brought in. The casualties are evacuated as quickly

as possible by field ambulances or helicopters. At a company station,

medical officers and medical corpsmen may provide further treatment before

patients are evacuated to the main dressing station at the field ambulance

headquarters, where a surgeon may perform emergency operations. Thereafter,

evacuation may be to casualty clearing stations, to advanced hospitals, or to

base hospitals. Air evacuation is widely used.

In peacetime most of the intermediate medical units exist only in skeleton

form; the active units are at the battalion and hospital level. When

physicians join the medical corps, they may join with specialist

qualifications, or they may obtain such qualifications while in the army. A

feature of army medicine is promotion to administrative positions. The

commanding officer of a hospital and the medical officer at headquarters may

have no contacts with actual patients.

Although medical officers in peacetime have some choice of the kind of work

they will do, they are in a chain of command and are subject to military

discipline. When dealing with patients, however, they are in a special

position; they cannot be ordered by a superior officer to give some

treatment or take other action that they believe is wrong. Medical officers

also do not bear or use arms unless their patients are being attacked.

Naval and air force medicine. Naval medical services are run on lines

similar to those of the army. Junior medical officers are attached to ships or

to shore stations and deal with most cases of sickness in their units. When at

sea. medical officers have an exceptional degree of responsibility in that

they work alone, unless they are on a very large ship. In peacetime, only the

larger ships carry a medical officer; in wartime, destroyers and other small

craft may also carry medical officers. Serious cases go to either a shore-based

hospital or a hospital ship.

Flying has many medical repercussions. Cold, lack of oxygen, and changes of

direction at high speed all have important effects on bodily and mental

functions. Armies and air forces may share the same medical services.

A developing field is aerospace medicine. This involves medical problems that

were not experienced before space-flight, for the main reason that humans in

space are not under the influence of gravity, a condition that has profound

physiological effects.

CLINICAL RESEARCH

The remarkable developments in medicine that have been brought about in the

20th century, especially since World War II, have been based on research

either in the basic sciences related to medicine or in the clinical field.

Advances in the use of radiation, nuclear energy, and space research have

played an important part in this progress. Some laypersons often think of

research as taking place only in sophisticated laboratories or highly

specialized institutions where work is devoted to scientific advances that

may or may not be applicable to medical practice. This notion, however,

ignores the clinical research that takes place on a day-to-day basis in

hospitals and doctors' offices.

Historical notes. Although the most spectacular changes in the medical

scene during the 20lh century, and the most widely heralded, have been the

development of potent drugs and elaborate operations, another striking change

has been the abandonment of most of the remedies of the past. In the mid-19th

century, persons ill with numerous maladies were starved (partially or

completely), bled, purged, cupped (by applying a tight-fitting vessel filled

with steam to some part and then cooling the vessel), and rested, perhaps for

months or even years. Much more recently they were prescribed various

restricted diets and were routinely kept in bed for weeks after abdominal

operations, for many weeks or months when their hearts were thought to be

affected, and for many months or years with tuberculosis. The abandonment of

these measures may not be though of as involving research, but the physician

who first encouraged persons who had peptic ulcers to eat normally (rather than

to live on the customary bland foods) and the physician who first got his

patients out of bed a week or two after they had had minor coronary thrombosis

(rather than insisting on a minimum of six weeks of strict bed rest) were as

much doing research as is the physician who first tries out a new drug on a

patient. This research, by observing what happens when remedies are abandoned,

has been of inestimable value, and the need for it has not passed.

Clinical observation. Much of the investigative clinical field work

undertaken in the present day requires only relatively simple laboratory

facilities because it is observational rather than experimental in character.

A feature of much contemporary medical research is that it requires the

collaboration of a number of persons, perhaps not all of them doctors. Despite

the advancing technology, there is much to be learned simply from the

observation and analysis of the natural history of disease processes as they

begin to affect patients, pursue their course, and end, either in their

resolution or by the death of the patient. Such studies may be suitably

undertaken by physicians working in their offices who are in a better position

than doctors working only in hospitals to observe the whole course of an

illness. Disease rarely begins in a hospital and usually does not end there. It

is notable, however, that observational research is subject to many limitations

and pitfalls of interpretation, even when it is carefully planned and

meticulously carried out.

Drug research. The administration of any medicament, especially a new

drug, to a patient is fundamentally an experiment: so is a surgical operation,

particularly if it involves a modification to an established technique or a

completely new procedure. Concern for the patient, careful observation,

accurate recording, and a detached mind are the keys to this kind of

investigation, as indeed to all forms of clinical study. Because patients are

individuals reacting to a situation in their own different ways, the data

obtained in groups of patients may well require statistical analysis for their

evaluation and validation.

One of the striking characteristics in the medical field in the 20th century

has been the development of new drugs, usually by pharmaceutical companies.

Until the end of the 19th century, the discovery of new drugs was largely a

matter of chance. It was in that period that Paul Ehrlich, the German

scientist, began to lay down the principles for modern pharmaceutical

research that made possible the development of a vast array of safe and

effective drugs. Such benefits, however, bring with them their own

disadvantages: it is estimated that as many as 30 percent of patients in, or

admitted to, hospitals suffer from the adverse effect of drugs prescribed by

a physician for their treatment. Sometimes it is extremely difficult to

determine whether a drug has been responsible for some disorder. An example

of the difficulty is provided-by the thalidomide disaster between 1959 and

1962. Only after numerous deformed babies had been born throughout the world

did it become clear that thalidomide taken by the mother as a sedative had

been responsible.

In hospitals where clinical research is carried out, ethical committees often

consider each research project. If the committee believes that the risks are

not justified, the project is rejected.

After a potentially useful chemical compound has been identified in the

laboratory, it is extensively tested in animals, usually for a period of

months or even years. Few drugs make it beyond this point. If the tests are

satisfactory, the decision may be made for testing the drug in humans. It is

this activity that forms the basis of much clinical research. In most

countries the first step is the study of its effects in a small number of

health volunteers. The response, effect on metabolism, and possible toxicity

are carefully monitored and have to be completely satisfactory before the

drug can be passed for further studies, namely with patients who have the

disorder for which the drug is to be used. Tests are administered at first to

a limited number of these patients to determine effectiveness, proper dosage,

and possible adverse reactions. These searching studies are scrupulously

controlled under stringent conditions. Larger groups of patients are

subsequently involved to gain a wider sampling of the information. Finally, a

full-scale clinical trial is set up. If the regulatory authority is satisfied

about the drug's quality, safely, and efficacy. it receives a license to be

produced. As the drug becomes more widely used, it eventually finds its

proper place in therapeutic practice, a process that may take years.

An important step forward in clinical research was taken in the mid-20th

century with the development of the controlled clinical trial. This sets out

to compare two groups of patients, one of which has had some form of

treatment that the other group has not. The testing of a new drug is a case

in point: one group receives the drug. the her a product identical in

appearance, but which is known to be inerta so-called placebo. At the end of

the trial, the results of which can be assessed in various ways, it can be

determined whether or not the drug is effective and safe. By the same

technique two treatments can be compared, for example a new drug against a

more familiar one. Because individuals differ physiologically and

psychologically, the allocation of patients between the two groups must be

made in a random fashion; some method independent of human choice must be

used so that such differences are distributed equally between the two groups.

In order to reduce bias and make the trial as objective as possible the

double-blind technique is sometimes used. In this procedure, neither the

doctor nor the patients know which of two treatments is being given. Despite

such precautions the results of such trials can be prejudiced, so that

rigorous statistical analysis is required. It is obvious that many ethical,

not to say legal, considerations arise, and it is essential that all patients

have given their informed consent to be included. Difficulties arise when

patients are unconscious, mentally confused, or otherwise unable to give

their informed consent. Children present a special difficulty because not all

laws agree that parents can legally commit a child to an experimental

procedure. Trials, and indeed all forms of clinical research that involve

patients, must often be submitted to a committee set up locally to scrutinize

each proposal.

Surgery. In drug research the essential steps are taken by the chemists

who synthesize or isolate new drugs in the laboratory; clinicians play only a

subsidiary part. In developing new surgical operations clinicians play a more

important role, though laboratory scientists and others in the background may

also contribute largely. Many new operations have been made possible by

advances in anesthesia, and these in turn depend upon engineers who have

devised machines and chemists who have produced new drugs. Other operations are

made possible by new materials, such as the alloys and plastics that are used

to make .artificial hip and knee joints.

Whenever practicable, new operations are tried on animals before they are

tried on patients. This practice is particularly relevant to organ

transplants. Surgeons themselvesnot experimental physiologiststransplanted

kidneys, livers, and hearts in animals before attempting these procedures on

patients. Experiments on animals are of limited value, however, because

animals do not suffer from all of the same maladies as do humans.

Many other developments in modem surgical treatment rest on a firm basis of

experimentation, often first in animals but also in humans; among them are

renal dialysis (the artificial kidney), arterial bypass operations, embryo

implantation, and exchange transfusions. These treatments are but a few of

the more dramatic of a large range of therapeutic measures that have not only

provided patients with new therapies but also have led to the acquisition of

new knowledge of how the body works. Among the research projects of the late

20th century is that of gene transplantation, which has the potential of

providing cures for cancer and other diseases.

SCREENING PROCEDURES

Developments in modem medical science have made it possible to detect morbid

conditions before a person actually feels the effects of the condition.

Examples arc many: they include certain forms of cancer; high blood pressure;

heart and lung disease; various familial and congenital conditions; disorders

of metabolism, like diabetes; and acquired immune deficiency syndrome (AIDS),

the consideration to be made in screening is whether or not such potential

patients should be identified by periodic examinations. To do so is to imply

that the subjects should be made aware of their condition and, second, that

there are effective measures that can be taken to prevent their condition, if

they test positive, from worsening. Such so-called specific screening

procedures are costly since they involve large numbers of people. Screening

may lead to a change in the life-style of many persons, but not all such

moves have been shown in the long run to be fully effective. Although

screening clinics may not be run by doctors, they are a factor of increasing

importance in the, preventive health service.

Periodic general medical examination of various sections of the population,

business executives for example, is another way of identifying risk factors

that, if not corrected, can lead to the development of overt disease.


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