The practice of modern medicine
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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 îf 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. Thå 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 ðåàãåíòå 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.
