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 оf 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 groups—women,

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. Breathlessness—a common symptom—may

be due to heart disease, to lung disease, to anemia, or to emotional upset.

Another common symptom is general malaise—feeling 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. Thе 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 schools—an exceptional state of

affairs—and 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 practitioners—a

far higher proportion than in most other advanced countries—though, 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 care—of 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

specialties—such as surgery, internal medicine, obstetrics and gynecology

and psychiatry—and 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 реагенте 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 inert—a 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 themselves—not experimental

physiologists—transplanted 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.