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The practice of modern medicine


1. Health care and its delivery
3. Levels of health care.
4. Costs of health care.
7. Britain.
8. United Stales.
9. Russia.
10. Japan.
11. Other developed countries.
13. China
14. India.
17. Specialties in medicine.
18. Teaching.
19. Industrial medicine.
20. Family health care.
21. Geriatrics.
22. Public health practice.
23. Military practice.
25. Historical notes.
26. Clinical observation.
27. Drug research.
28. Surgery.

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.

"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
 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
Levels of health care.
In the curative domain there are various forms  f  medical  practice.  They
may be thought of generally as forming a  pyramidal  structure,  with  three
tiers  representing  increasing  degrees  of  specialization  and  technical
sophistication but catering to diminishing numbers of patients as  they  are
filtered out of the system  at  a  lower  level.  Only  those  patients  who
require special attention or treatment should reach  the  second  (advisory)
or third (specialized treatment) tiers where the cost per  item  of  service
becomes increasingly higher.  The  first  level  represents  primary  health
care, or first contact care, or which patients have  their  initial  contact
with the health-care system.
 Primary health care is an integral part of a country's  health  maintenance
system, of which it forms the largest and most important part. As  described
in the declaration of Alma-Ata, primary health  care  should  be  "based  on
practical  scientifically  sound  and  socially   acceptable   methods   and
technology made universally  accessible  to  individuals  in  the  community
through their full participation and  at  a  cost  that  the  community  and
country can afford to maintain at every stage of then development."  Primary
health care in  the  developed  countries  is  usually  the  province  of  a
medically qualified physician; in the  developing  countries  first  contact
care is often provided by nonmedically qualified personnel.
 The vast majority of patients can be fully dealt with at the primary level.
Those who cannot are referred to the second tier (secondary health care,  or
the referral services) for the opinion  of  a  consultant  with  specialized
knowledge or for X-ray examinations  and  special  tests.  Secondary  health
care often requires the technology offered by a local or regional  hospital.
Increasingly, however, the radiological and laboratory services provided  by
hospitals are available directly to the family doctor,  thus  improving  his
service to palings and increasing its range. The third tier of  health  care
employing specialist services, is offered by institutions such  as  leaching
hospitals  and  units  devoted  to  the  care  of  particular  groupswomen,
children,  patients  with  mental  disorders,  and  so  on.   The   dramatic
differences in the cost of treatment at the various levels is  a  matter  of
particular importance in developing countries, where the cost  of  treatment
for patients at the primary  health-care  level  is  usually  only  a  small
fraction of that at the third level- medical costs  at  any  level  in  such
countries, however, are usually borne by the government.
 Ideally, provision of health care at all levels will be  available  to  all
patients; such health care may be said to be universal. The  well-off,  both
in relatively wealthy industrialized countries and in the poorer  developing
world, may be able to get medical attention from  sources  they  prefer  and
can pay for in the private sector. The  vast  majority  of  people  in  most
countries, however, are dependent  in  various  ways  upon  health  services
provided by the state, to which they  may  contribute  comparatively  little
or, in the case of poor countries, nothing at all.
 Costs of health care. The costs to national economics of  providing  health
care are considerable and have been growing at a  rapidly  increasing  rate,
especially in countries such as the United States, Germany, and Sweden;  the
rise in Britain has been less rapid. This trend has been the cause of  major
concerns in both developed and developing countries. Some  of  this  concern
is based upon the  lack  of  any  consistent  evidence  to  show  that  more
spending on health care produces better  health.  There  is  a  movement  in
developing countries to replace the  type  of  organization  of  health-care
services  that  evolved  during  European  colonial  times  with  some  less
expensive, and for them, more appropriate, health-care system.
 In the industrialized world the growing cost of health services has  caused
both private and public health-care delivery  systems  to  question  current
policies and to seek more  economical  methods  of  achieving  their  goals.
Despite expenditures, health services are not  always  used  effectively  by
those who  need  them,  and  results  can  vary  widely  from  community  to
community. In Britain, for example, between 1951 and  1971  the  death  rate
fell by 24 percent in the wealthier sections of the population but  by  only
half that in the most underprivileged sections of society.  The  achievement
of good health is reliant upon more than just the quality  of  health  care.
Health entails such factors as good education, safe  working  conditions,  a
favourable  environment,  amenities  in  the  home,  well-integrated  social
services, and reasonable standards of living.
 In the developing countries.  The  developing  countries  differ  from  one
another culturally, socially,  and  economically,  but  what  they  have  in
common is a low average income per person, with large percentages  of  their
populations living at or below the  poverty  level.  Although  most  have  a
small elite class, living mainly in the cities, the largest  part  of  their
populations live in rural  areas.  Urban  regions  in  developing  and  some
developed countries in  the  mid-  and  late  20th  century  have  developed
pockets of slums, which are growing because of an influx of  rural  peoples.
For lack of even the simplest measures, vast  numbers  of  urban  and  rural
poor die each year of preventable and  curable  diseases,  often  associated
with poor hygiene  and  sanitation,  impure  water  supplies,  malnutrition,
vitamin deficiencies, and chronic  preventable  infections.  The  effect  of
these and other deprivations is reflected by the finding that in  the  1980s
the life expectancy at birth for men and women was about one-third  less  in
Africa than it was in Europe; similarly,  infant  mortality  in  Africa  was
about eight times greater than in Europe. The extension of  primary  health-
care services is therefore a high priority in the developing countries.
 The developing countries themselves, lacking  the  proper  resources,  have
often been unable to generate or implement the plans  necessary  to  provide
required services at the village or  urban  poor  level.  It  has,  however,
become clear that the system of health care  that  is  appropriate  for  one
country is often unsuitable  for  another.  Research  has  established  that
effective health care  is  related  to  the  special  circumstances  of  the
individual country, its people, culture, ideology, and economic and  natural
 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.

In many parts of the world, particularly  in  developing  countries,  people
get their primary health care, or first-contact  care,  where  available  at
all,  from  nonmedically  qualified  personnel;  these  cadres  of   medical
auxiliaries are being trained in increasing  numbers  to  meet  overwhelming
needs among  rapidly  growing  populations.  Even  among  the  comparatively
wealthy countries of the world, containing in all a much smaller  percentage
of the world's population, escalation in the costs of  health  services  and
in the cost of training a physician has precipitated  some  movement  toward
reappraisal of the role of the medical doctor  in  the  delivery  of  first-
contact care.
 In  advanced  industrial  countries,  however,  it  is  usually  a  trained
physician who is called upon to provide the first-contact care. The  patient
seeking first-contact care can go either to a general practitioner  or  turn
directly to a specialist. Which is the wisest choice has  become  a  subject
of some controversy. The general practitioner, however, is  becoming  rather
rare in some developed countries. In countries where he  does  still  exist,
he  is  being  increasingly  observed  as  an  obsolescent  figure,  because
medicine covers an immense, rapidly changing, and complex field of which  no
physician can possibly master more than a small fraction. The  very  concept
of the general practitioner, it is thus argued, may be absurd.
 The obvious alternative to general practice  is  the  direct  access  of  a
patient to a specialist. If a patient has problems with vision, he  goes  to
an eye specialist, and if he has a pain in his chest (which he fears is  due
to his heart), he goes to a heart specialist. One objection to this plan  is
that the patient often cannot  know  which  organ  is  responsible  for  his
symptoms, and the most careful physician, after doing  many  investigations,
may remain uncertain as to the cause.  Breathlessnessa  common  symptommay
be due to heart disease, to lung disease, to anemia, or to emotional  upset.
Another common symptom is general malaisefeeling run-down or always  tired;
others  are  headache,   chronic   low   backache,   rheumatism,   abdominal
discomfort, poor appetite, and  constipation.  Some  patients  may  also  be
overtly anxious or depressed. Among the most subtle medical  skills  is  the
ability to assess people with  such  symptoms  and  to  distinguish  between
symptoms that are caused predominantly by emotional  upset  and  those  that
are predominantly of bodily origin. A specialist may be capable  of  such  a
general assessment, but, often, with emphasis on his own subject,  he  fails
at this point. The generalist with his broader training is often the  better
choice for a first diagnosis, with referral to  a  specialist  as  the  next
 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.

 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
 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
 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
 Patients in the United States may also choose to be treated by  doctors  of
osteopathy. These doctors are fully qualified,  but  they  make  up  only  a
small percentage of the country's physicians. They may also branch off  into
specialties, hut general practice is much more common in  their  group  than
among M.D.'s.
 It used to be more common in the United  States  for  physicians  providing
primary care to  work  independently,  providing  their  own  equipment  and
paying their own ancillary staff. In smaller cities  they  mostly  had  full
hospital privileges, but in larger cities these privileges were more  likely
to be restricted.  Physicians,  often  sharing  the  same  specialties,  are
increasingly entering into group associations, where the expenses of  office
space, staff, and equipment may be shared; such associations  may  work  out
of  suites  of  offices,  clinics,  or  medical  centres.   The   increasing
competition and risks of private practice have  caused  many  physicians  to
join Health Maintenance Organizations (HMOs),  which  provide  comprehensive
medical. care and hospital care on a prepaid  basis.  Th  cost  savings  to
patient's are considerable, but they must  use  only  the  HMO  doctors  and
facilities. HMOs stress preventive medicine  and  out-patient  treatment  as
opposed to hospitalization as a means of reducing costs, a policy  that  has
caused an increased number of empty hospital beds in the United States.
 While the number of doctors per 100,000 population in the United States has
been steadily increasing, there has been a  trend  among  physicians  toward
the use of trained medical personnel to handle some of  the  basic  services
normally performed by the doctor. So-called physician extender services  are
commonly divided into nurse practitioners and physician's  assistants,  both
of whom provide similar ancillary services for the general  practitioner  or
specialist. Such personnel do not replace the doctor.  Almost  all  American
physicians have systems for taking  each  other's  calls  when  they  become
unavailable. House calls in the United Stales, as in  Britain,  have  become
exceedingly rare.
 Russia. In  Russia  general  practitioners  are  prevalent  in  the  thinly
populated rural areas. Pediatricians deal with children up to about age  15.
Internists  look  after  the  medical  ills  of  adults,  and   occupational
physicians deal with the workers, sharing care with internists.
 Teams of physicians  with  experience  in  varying  specialties  work  from
polyclinics or outpatient units, where many types of diseases  are  treated.
Small towns usually have one polyclinic to serve all purposes. Large  cities
commonly have separate polyclinics for  children  and  adults,  as  well  as
clinics with specializations such as women's health care, mental  illnesses,
and sexually transmitted diseases. Polyclinics usually have X-ray  apparatus
and facilities for examination of tissue  specimens,  facilities  associated
with the departments of the district hospital. Beginning in the  late  1970s
was a trend toward the development of  more  large,  multipurpose  treatment
centres, first-aid hospitals,  and  specialized  medicine  and  health  care
 Home visits have traditionally been common, and  much  of  the  physician's
time is spent in performing routine checkups for preventive  purposes.  Some
patients in sparsely populated rural areas may be seen  first  by  feldshers
(auxiliary  health  workers),  nurses,  or  midwives  who  work  under   the
supervision of a polyclinic or hospital physician. The feldsher was  once  a
lower-grade physician in the army or peasant communities, but feldshers  are
now regarded as paramedical workers.
 Japan. In  Japan,  with  less  rigid  legal  restriction  of  the  sale  of
pharmaceuticals than in the West, there was formerly a strong  tradition  of
self-medication and  self-treatment.  This  was  modified  in  1961  by  the
institution of health insurance programs that covered a large proportion  of
the population; there was then a great increase in visits to the  outpatient
clinics of hospitals and to private clinics and individual physicians.
 When Japan shifted from traditional Chinese medicine with the  adoption  of
Western medical practices in the 1870s. Germany became the chief  model.  As
a  result  of  German  influence  and  of  their  own  traditions,  Japanese
physicians tended to  prefer  professorial  status  and  scholarly  research
opportunities  at  the  universities  or  positions  in  the   national   or
prefectural hospitals  to  private  practice.  There  were  some  pioneering
physicians, however, who brought medical care to the ordinary people.
 Physicians in Japan have tended to cluster in the urban areas. The  Medical
Service Law of 1963 was amended  to  empower  the  Ministry  of  Health  and
Welfare to control the  planning  and  distribution  of  future  public  and
nonprofit medical facilities, partly to redress the  urban-rural  imbalance.
Meanwhile, mobile services were expanded.
 The influx of patients into hospitals and private clinics after the passage
of the national health insurance acts of 1961 had, as one effect,  a  severe
reduction in the amount of time available for any one  patient.  Perhaps  in
reaction to this situation, there  has  been  a  modest  resurgence  in  the
popularity of traditional Chinese medicine, with  its  leisurely  interview,
its dependence on herbal  and  other  "natural"  medicines,  and  its  other
traditional diagnostic and therapeutic practices. The  rapid  aging  of  the
Japanese population as a result of the sharply  decreasing  death  rate  and
birth rate has created an urgent need for expanded health care services  /or
the elderly. There has also been an increasing need  for  centres  to  treat
health problems resulting from environmental causes.
 Other developed countries. On the  continent  of  Europe  there  are  great
differences both within single countries and between countries in the  kinds
of first-contact medical care. General practice, while declining  in  Europe
as elsewhere, is still rather common even in some large cities, as  well  as
in remote country areas.
 In The Netherlands, departments of general  practice  are  administered  by
general practitioners in all the medical  schoolsan  exceptional  state  of
affairsand general practice flourishes. In the larger  cities  of  Denmark,
general practice on an individual basis is usual and  popular,  because  the
physician works only during office hours.  In  addition,  there  is  a  duty
doctor service for nights and weekends. In the  cities  of  Sweden,  primary
care is given by specialists. In the  remote  regions  of  northern  Sweden,
district doctors act as general practitioners to patients spread  over  huge
areas; the district doctors delegate much of their home visiting to nurses.
 In France there are  still  general  practitioners,  but  their  number  is
declining. Many medical practitioners advertise themselves directly  to  the
public   as   specialists   in    internal    medicine,    ophthalmologists,
gynecologists, and other kinds of specialists. Even  when  patients  have  a
general practitioner, they may still go directly to a  specialist.  Attempts
to stem the decline in general practice are being made  hy  the  development
of group practice and of small rural hospitals equipped to  deal  with  less
serious  illnesses,  where  general  practitioners  can  look  after   their
 Although Israel has a high ratio of physicians to population,  there  is  a
shortage of general practitioners,  and  only  in  rural  areas  is  general
practice common. In the towns many  people  go  directly  to  pediatricians,
gynecologists, and other specialists, but there has been a reaction  against
this direct access to the specialist. More general practitioners  have  been
trained, and the Israel Medical Association has recommended that no  patient
should be referred to a specialist except by  the  family  physician  or  on
instructions given by the family nurse. At Tel Aviv University  there  is  a
department of family medicine. In some newly  developing  areas,  where  the
doctor shortage  is  greatest,  there  are  medical  centres  at  which  all
patients are initially interviewed by a nurse. The nurse may deal with  many
minor ailments, thus freeing the physician to treat the more seriously ill.
 Nearly half the medical doctors in Australia  are  general  practitionersa
far higher proportion than  in  most  other  advanced  countriesthough,  as
elsewhere, their numbers are declining. They tend to do far more  for  their
patients than in Britain, many performing such operations as removal of  the
appendix,  gallbladder,  or  uterus,  operations  that  elsewhere  would  be
carried out by a specialist surgeon. Group practices are common.

 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
 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
 India. Ayurvedic medicine is an  example  of  a  well-organized  system  of
traditional health care,  both  preventive  and  curative,  that  is  widely
practiced in parts of Asia. Ayurvedic medicine has a long  tradition  behind
it, having originated in India perhaps as long as 3.000  years  ago.  It  is
still a favoured form of health care in large parts of  the  Eastern  world,
especially in India, where a large percentage of  the  population  use  this
system exclusively or combined with  modern  medicine.  The  Indian  Medical
Council  was  set  up  in  1971  by  the  Indian  government  to   establish
maintenance of standards for undergraduate and  postgraduate  education.  It
establishes  suitable  qualifications  in  Indian  medicine  and  recognizes
various forms  of  traditional  practice  including  Ayurvedic.  Unani.  and
Siddha. Projects have been undertaken to  integrate  the  indigenous  Indian
and Western forms of medicine. Most Ayurvedic practitioners  work  in  rural
areas, providing health care to at least 500,000.000 people in India  alone.
They therefore represent a major force for primary health  care,  and  their
training and deployment are important to the government of India.
 Like scientific  medicine,  Ayurvedic  medicine  has  both  preventive  and
curative aspects. The preventive component emphasizes the need for a  strict
code of personal and social  hygiene,  the  details  of  which  depend  upon
individual, climatic, and environmental needs. Rodilv exercises, the use  of
herbal preparations, and Yoga form a part  of  the  remedial  measures.  The
curative  aspects  of  Avurvcdic  medicine  involves  the  use   of   herbal
medicines,  'external  preparations,  physiotherapy,  and  diet.  It  is   a
principle  of  Ayurvedic  medicini.  that  the  preventive  and  therapeutic
measures be adapted to the personal requirements of each patient.
 Other developing countries. A main goal of the  World  Health  Organization
(WHO), as expressed in the Alma-Ata Declaration of 1978, is  to  provide  to
all the citizens of the world a level of health  that  will  allow  them  to
lead socially and economically productive lives by the  year  2000.  By  the
late 1980s, however, vast disparities in health care still  existed  between
the rich and poor countries of the world. In developing  countries  such  as
Ethiopia, Guinea, Mali, and Mozambique, for  instance,  governments  in  the
late 1980s spent less than $5 per person per year on  public  health,  while
in most western European countries several  hundred  dollars  per  year  was
spent on  each  person.  The  disproportion  of  the  number  of  physicians
available between developing and developed countries is similarly wide.
 Along with the shortage of physicians, there is a  shortage  of  everything
else needed to  provide  medical  careof  equipment,  drugs,  and  suitable
buildings, and of nurses, technicians, and all other grades of staff,  whose
presence is taken for granted in  the  affluent  societies.  Yet  there  are
greater percentages  of  sick  in  the  poor  countries  than  in  the  rich
countries. In the poor countries a high proportion of people are young,  and
all  are  liable  to  many  infections,  including  tuberculosis,  syphilis,
typhon). and cholera (which, with the possible exception  of  syphilis,  are
now rare in the rich countries), and also malaria, yaws. worm  infestations,
and many other  conditions  occurring  primarily  in  the  warmer  climates.
Nearly all of these infections respond to the antibiotics  and  other  drugs
that have been discovered since the 1920s. There is also  much  malnutrition
and anemia, which  can  be  cured  if  funding  is  available.  There  is  a
prevalence of disorders  remediable  by  surgery.  Preventive  medicine  can
ensure clean water supplies, destroy insects that  carry  infections,  teach
hygiene, and show how to make the best use of resources.
 In most poor countries there are  a  few  people,  usually  living  in  the
cities, who can afford to pay for medical care and in a free  market  system
the physicians lend to  go  where  they  can  make  the  best  living;  this
situation causes the doctor-patient ratio to be much  higher  in  the  towns
than in country districts. A physician in Bombay or in Rio de  Janeiro,  for
example, may have equipment as lavish as that of a physician in  the  United
States and can earn an excellent income. The  poor,  however,  both  in  the
cities and in the country, can gel medical attention only if it is paid  for
by the state,  by  some  supranational  body,  or  by  a  mission  or  other
charitable organization. Moreover, the quality of the care they  receive  is
often poor,  and  in  remote  regions  it  may  be  lacking  altogether.  In
practice, hospitals run by a mission may cooperate  closely  with  stale-run
health centres.
Because physicians are scarce, their skills must be used to best advantage,
and much of the work normally done by physicians in the rich  countries  has
to be delegated to auxiliaries or nurses, who have to  diagnose  the  common
conditions, give  treatment,  take  blood  samples,  help  with  operations,
supply simple posters containing health advice, and carry out  other  tasks.
In such places the doctor has lime only  to  perform  major  operations  and
deal with the more difficult medical problems. People are treated as far  as
possible on an  outpatient  basis  from  health  centres  housed  in  simple
buildings; few can travel except on foot, and, if they are more than  a  few
miles from a health centre, they tend not to go there. Health  centres  also
may be used for health education.
Although primary health-care service diners from country to  country,  that
developed in Tanzania is representative of many that have  been  devised  in
largely rural developing  countries.  The  most  important  feature  of  the
Tanzanian rural health service is the rural health centre, which,  with  its
related dispensaries, is intended to provide comprehensive  health  services
for the community. The staff is headed by the assistant medical officer  and
the medical assistant. The assistant  medical  officer  has  at  least  lour
years of experience, which is then  followed  by  further  training  for  18
months. He is not a doctor but serves to  bridge  the  gap  between  medical
assistant and physician. The medical assistant has three  years  of  general
medical education. The work of the rural health centres and dispensaries  is
mainly of three kinds: diagnosis and treatment, maternal and  child  health,
and environmental health. The main  categories  of  primary  health  workers
also include medical aids,  maternal  and  child  health  aids,  and  health
auxiliaries. Nurses and midwives form another category  of  worker.  In  the
villages there are village health posts staffed by village  medical  helpers
working under supervision from the rural health centre.
In some primitive elements of the societies of developing countries, and of
some developed countries, there exists the belief that  illness  comes  from
the displeasure  of  ancestral  gods  and  evil  spirits,  from  the  malign
influence of evil disposed persons,  or  from  natural  phenomena  that  can
neither he forecast nor controlled. To deal with such causes there are  many
varieties of indigenous healers who practice elaborate rituals on behalf  of
both the physically ill and the mentally  afflicled.  If  it  is  understood
that such beliefs, and other forms of shamanism, may provide  a  basis  upon
which health care can be based, then primary health  care  may  he  said  to
exist almost everywhere. It is not only easily available  but  also  readily
acceptable, and often preferred, to more rational methods of  diagnosis  and
treatment. Although such methods may sometimes be harmful,  they  may  often
be effective, especially where the cause is psychosomatic.  Other  patients,
however, may suffer from a disease for which  there  is  a  cure  in  modern
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.

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.

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
To provide more efficient service it  is  not  uncommon  for  a  specialist
surgeon and a specialist physician to form a team working  together  in  the
field of, for example, heart disease. An advantage of  this  arrangement  is
that they can attract a  highly  trained  group  of  nurses,  technologists.
operating  room  technicians,  and  so  on,  thus  greatly   improving   the
efficiency of the service to the patient. Such specialization is  expensive,
however, and has required an increasingly large  proportion  of  the  health
budget of institutions,  a  situation  that  eventually  has  its  financial
effect on the individual citizen. The question therefore arises as to  their
cost-effectiveness. Governments of developing countries have usually  found,
for instance, that it is more cost-efficient to  provide  more  people  with
basic care.
 Teaching. Physicians in developed  countries  frequently  prefer  posts  in
hospitals with medical schools. Newly  qualified  physicians  want  to  work
there because doing so will aid their  future  careers,  though  the  actual
experience may be wider and better in a hospital without a  medical  school.
Senior physicians seek careers in hospitals  with  medical  schools  because
consultant, specialist, or professorial posts there  usually  carry  a  high
degree  of  prestige.  When  the  posts  are  salaried,  the  salaries   are
sometimes, but not always, higher than in a nonteaching hospital. Usually  a
consultant who works in private practice earns more when on the staff  of  a
medical school.
 In many medical schools there are clinical professors in each of the  major
specialtiessuch as surgery, internal medicine,  obstetrics  and  gynecology
and psychiatryand often of the smaller specialties as well. There are  also
professors of pathology, radiology, and radiotherapy. Whether professors  or
not, all doctors in teaching hospitals have the two functions of caring  for
the sick and educating students. They give lectures  and  seminars  and  are
accompanied by students on ward rounds.
 Industrial medicine. The Industrial Revolution greatly changed,  and  as  a
rule worsened, the health hazards caused by industry, while the  numbers  at
risk vastly increased. In Britain the first small beginnings of  efforts  to
ameliorate the lot of the workers in factories and mines began in 1802  with
the passing of the first factory act, the Health and Morals  of  Apprentices
Act. The factory act  of  1838,  however,  was  the  first  truly  effective
measure in the industrial field. It forbade  night  work  for  children  and
restricted their work hours to 12 per day. Children under 13  were  required
to attend School. A factory inspectorate  was  established,  the  inspectors
being given powers of entry into  factories  and  power  of  prosecution  of
recalcitrant  owners.  Thereafter  there  was  a  succession  of  acts  with
detailed regulations for safety and health  in  all  industries.  Industrial
diseases were made  notifiable,  and  those  who  developed  any  prescribed
industrial disease were entitled to benefits.
 The situation is similar in other developed countries. Physicians are bound
by legal restrictions and must report industrial  diseases.  The  industrial
physician's most important  function,  however,  is  to  prevent  industrial
diseases. Many of the measures to this end have  become  standard  practice,
but, especially in industries working with  new  substances,  the  physician
should determine  if  workers  are  being  damaged  and  suggest  preventive
measures. The industrial physician may advise  management  about  industrial
hygiene and the need for safety devices  and  protective  clothing  and  may
become involved in building design. The physician or health worker may  also
inform the worker of occupational health hazards.
 Modern factories usually have arrangements for giving first aid in case  of
accidents. Depending upon the size of the plant, the  facilities  may  range
from a simple first-aid station to a large suite of lavishly equipped  rooms
and may include a staff of qualified nurses and physiotherapists and one  or
perhaps more full-time physicians.
 Periodic medical examination. Physicians  in  industry  carry  out  medical
examinations, especially on new employees and on  those  returning  to  work
after sickness or injury. In addition, those liable to  health  hazards  may
be examined regularly  in  the  hope  of  detecting  evidence  of  incipient
damage. In some organizations  every  employee  may  be  offered  a  regular
medical examination.
 The industrial and the  personal  physician.  When  a  worker  also  has  a
persona! physician,  there  may  be  doubt.  in  some  cases,  as  to  which
physician bears the main responsibility for his health. When someone has  an
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
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
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
 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
Former Soviet Union. In the aftermath of  the  dissolution  of  the  Soviet
Union, responsibility for public health  fell  to  the  governments  of  the
successor countries.
The public health services for the U.S.S.R. as a whole were directed by the
Ministry of Health. The ministry, through the 15 union  republic  ministries
of health, directed all medical institutions within its competence  as  well
as the public health authorities; and services throughout the country.
The administration was centralized, with little local autonomy. Each of the
15 republics had its own ministry  of  health,  which  was  responsible  for
carrying out the plans and decisions established by  the  U.S.S.R.  Ministry
of Health. Each republic was divided into oblasti, or provinces,  which  had
departments of health directly  responsible  to  the  republic  ministry  of
health. Each oblast, in turn, had rayony (municipalities), which have  their
own  health  departments  accountable  to  the  oblast  health   department.
Finally, each rayon was subdivided into smaller uchastoki (districts).
In most rural rayony the responsibility for  public  health  lay  with  the
chief physician,  who  was  also  medical  director  of  the  central  rayon
hospital. This system ensured unity  of  public  health  administration  and
implementation  of  the  principle  of  planned  development.  Other  health
personnel included nurses, feldshers, and midwives.
For more information on the history, organization, and progress  of  public
health, see below.
Military practice. The medical services of armies, navies, and  air  forces
are geared to war. During campaigns the first requirement is the  prevention
of sickness. In all wars before the 20th century, many more combatants  died
of disease than of wounds. And even in World War  II  and  wars  thereafter,
although few died of disease, vast numbers became casualties from disease.
 The main means of preventing sickness are the provision  of  adequate  food
and pure water, thus eliminating  starvation,  avitaminosis,  and  dysentery
and other bowel infections, which used to be particular scourges of  armies;
the provision of proper clothing and other  means  of  protection  from  the
weather; the elimination from the service of those likely to fall sick:  the
use of vaccination and suppressive  drugs  to  prevent  various  infections,
such as typhoid and malaria; and education in hygiene and in the  prevention
of sexually transmitted diseases, a particular problem in the  services.  In
addition, the maintenance of high morale has a sinking  effect  on  casualty
rates, for, when morale is poor, soldiers are likely to  suffer  psychiatric
breakdowns, and malingering is more prevalent.
The medical branch may provide advice about  disease  prevention,  but  the
actual execution of this advice is through the ordinary chains  of  command.
It is the duty of the military, not of the medical, officer to  ensure  that
the troops obey orders not to drink infected water and to  take  tablets  to
suppress malaria.
Army medical organisation.   The medical doctor of  first  contact  to  the
soldier in the armies of developed countries is usually an  officer  in  the
medical corps. In  the  doctor  sees  the  sick  and  has  functions
similar  to  those  of  the  general  practitioner,  prescribing  drugs  and
dressings and there may be a sick  bay  where  slightly  sick  soldiers  can
remain for a few days. The doctor is usually assisted by trained nurses  and
corpsmen. If a further medical opinion  is  required,  the  patient  can  be
referred to a specialist at a military or civilian hospital.
 In a war zone, medical officers have an aid post where, with  the  help  of
corpsmen, they apply first aid to  the  walking  wounded  and  to  the  more
seriously wounded who are  brought  in.  The  casualties  are  evacuated  as
quickly as possible  by  field  ambulances  or  helicopters.  At  a  company
station,  medical  officers  and  medical  corpsmen  may   provide   further
treatment before patients are evacuated to the main dressing station at  the
field  ambulance  headquarters,  where  a  surgeon  may  perform   emergency
operations. Thereafter, evacuation may be to casualty clearing stations,  to
advanced hospitals, or to base hospitals. Air evacuation is widely used.
 In peacetime most of the intermediate medical units exist only in  skeleton
form; the active units  are  at  the  battalion  and  hospital  level.  When
physicians  join  the  medical  corps,  they  may   join   with   specialist
qualifications, or they may obtain such qualifications while in the army.  A
feature of army medicine  is  promotion  to  administrative  positions.  The
commanding officer of a hospital and the  medical  officer  at  headquarters
may have no contacts with actual patients.
 Although medical officers in peacetime have some choice of the kind of work
they will do, they are in a chain of command and  are  subject  to  military
discipline. When dealing with patients,  however,  they  are  in  a  special
position; they cannot  be  ordered  by  a  superior  officer  to  give  some
treatment or take other action that they believe is wrong. Medical  officers
also do not bear or use arms unless their patients are being attacked.
 Naval and air force medicine. Naval  medical  services  are  run  on  lines
similar to those of the army. Junior medical officers are attached to  ships
or to shore stations and deal with most cases of sickness  in  their  units.
When at sea. medical officers have an exceptional degree  of  responsibility
in that they  work  alone,  unless  they  are  on  a  very  large  ship.  In
peacetime, only the larger  ships  carry  a  medical  officer;  in  wartime,
destroyers and other small craft may also carry  medical  officers.  Serious
cases go to either a shore-based hospital or a hospital ship.
 Flying has many medical repercussions. Cold, lack of oxygen, and changes of
direction at high speed all have important  effects  on  bodily  and  mental
functions. Armies and air forces may share the same medical services.
 A developing field is aerospace medicine. This  involves  medical  problems
that were not experienced before space-flight,  for  the  main  reason  that
humans in space are not under the influence of  gravity,  a  condition  that
has profound physiological effects.

The remarkable developments in medicine that have been brought about in  the
20th century, especially since World War II, have  been  based  on  research
either in the basic sciences related to medicine or in the  clinical  field.
Advances in the use of radiation, nuclear energy, and  space  research  have
played an important part in this progress. Some laypersons  often  think  of
research as taking  place  only  in  sophisticated  laboratories  or  highly
specialized institutions where work is devoted to scientific  advances  that
may or may not be applicable to  medical  practice.  This  notion,  however,
ignores the clinical research that takes place  on  a  day-to-day  basis  in
hospitals and doctors' offices.
 Historical notes. Although the most  spectacular  changes  in  the  medical
scene during the 20lh century, and the most widely heralded, have  been  the
development of potent  drugs  and  elaborate  operations,  another  striking
change has been the abandonment of most of the remedies of the past. In  the
mid-19th  century,  persons  ill  with  numerous   maladies   were   starved
(partially or completely),  bled,  purged,  cupped  (by  applying  a  tight-
fitting vessel filled with steam to some part and then cooling the  vessel),
and rested, perhaps for months or even years. Much more recently  they  were
prescribed various restricted diets and  were  routinely  kept  in  bed  for
weeks after abdominal operations,  for  many  weeks  or  months  when  their
hearts were thought to be affected,  and  for  many  months  or  years  with
tuberculosis. The abandonment of these measures may  not  be  though  of  as
involving research, but the physician who first encouraged persons  who  had
peptic ulcers to eat normally (rather than to live on  the  customary  bland
foods) and the physician who first got his patients out of  bed  a  week  or
two after they had had minor coronary thrombosis (rather than  insisting  on
a minimum of six weeks of strict bed rest) were as much  doing  research  as
is the physician who  first  tries  out  a  new  drug  on  a  patient.  This
research, by observing what happens when remedies are  abandoned,  has  been
of inestimable value, and the need for it has not passed.
 Clinical  observation.  Much  of  the  investigative  clinical  field  work
undertaken in the present day requires  only  relatively  simple  laboratory
facilities  because  it  is  observational  rather  than   experimental   in
character. A feature of  much  contemporary  medical  research  is  that  it
requires the collaboration of a number of persons, perhaps not all  of  them
doctors. Despite the advancing technology,  there  is  much  to  be  learned
simply from the observation and analysis of the natural history  of  disease
processes as they begin to affect patients, pursue their  course,  and  end,
either in their resolution or by the death of the patient. Such studies  may
be suitably undertaken by physicians working in their offices who are  in  a
better position than doctors working only in hospitals to observe the  whole
course of an illness. Disease rarely begins in a hospital and  usually  does
not end there. It  is  notable,  however,  that  observational  research  is
subject to many limitations and pitfalls of interpretation, even when it  is
carefully planned and meticulously carried out.
 Drug research. The administration of any medicament, especially a new drug,
to a patient is fundamentally an experiment: so  is  a  surgical  operation,
particularly if it involves a modification to an established technique or  a
completely new procedure. Concern  for  the  patient,  careful  observation,
accurate recording, and a detached  mind  are  the  keys  to  this  kind  of
investigation, as indeed to all forms of clinical  study.  Because  patients
are individuals reacting to a situation in their  own  different  ways,  the
data obtained in groups of patients may well  require  statistical  analysis
for their evaluation and validation.
 One of the striking characteristics  in  the  medical  field  in  the  20th
century has been the development of new  drugs,  usually  by  pharmaceutical
companies. Until the end of the 19th century, the  discovery  of  new  drugs
was largely a matter of chance. It was in that  period  that  Paul  Ehrlich,
the  German  scientist,  began  to  lay  down  the  principles  for   modern
pharmaceutical research that made possible the development of a  vast  array
of safe and effective drugs. Such benefits, however, bring with  them  their
own disadvantages: it is estimated that as many as 30  percent  of  patients
in, or admitted to, hospitals  suffer  from  the  adverse  effect  of  drugs
prescribed by a physician for their treatment.  Sometimes  it  is  extremely
difficult to  determine  whether  a  drug  has  been  responsible  for  some
disorder. An example  of  the  difficulty  is  provided-by  the  thalidomide
disaster between 1959 and 1962. Only  after  numerous  deformed  babies  had
been born throughout the world did it become clear  that  thalidomide  taken
by the mother as a sedative had been responsible.
 In hospitals where clinical research is  carried  out,  ethical  committees
often consider each research project. If the  committee  believes  that  the
risks are not justified, the project is rejected.
 After a potentially useful chemical compound has  been  identified  in  the
laboratory, it is extensively tested in animals, usually  for  a  period  of
months or even years. Few drugs make it beyond this point. If the tests  are
satisfactory, the decision may be made for testing the drug  in  humans.  It
is this activity that forms the basis of much  clinical  research.  In  most
countries the first step is the study of its effects in a  small  number  of
health  volunteers.  The  response,  effect  on  metabolism,  and   possible
toxicity are carefully monitored and  have  to  be  completely  satisfactory
before the drug can be passed for further studies, namely with patients  who
have the disorder for which the drug is to be used. Tests  are  administered
at first to a limited number of these patients to  determine  effectiveness,
proper dosage, and possible adverse reactions. These searching  studies  are
scrupulously  controlled  under  stringent  conditions.  Larger  groups   of
patients  are  subsequently  involved  to  gain  a  wider  sampling  of  the
information. Finally,  a  full-scale  clinical  trial  is  set  up.  If  the
regulatory authority is satisfied about  the  drug's  quality,  safely,  and
efficacy. it receives a license to be produced. As  the  drug  becomes  more
widely used, it eventually finds its proper place in  therapeutic  practice,
a process that may take years.
 An important step forward in clinical research was taken  in  the  mid-20th
century with the development of the controlled  clinical  trial.  This  sets
out to compare two groups of patients, one of which has  had  some  form  of
treatment that the other group has not. The testing of a new drug is a  case
in point: one group receives the  drug.  the  her  a  product  identical  in
appearance, but which is known to be inerta so-called placebo. At  the  end
of the trial, the results of which can be assessed in various ways,  it  can
be determined whether or not the drug is effective and  safe.  By  the  same
technique two treatments can be compared, for example a new drug  against  a
more  familiar  one.  Because   individuals   differ   physiologically   and
psychologically, the allocation of patients between the two groups  must  be
made in a random fashion; some method independent of human  choice  must  be
used so that such  differences  are  distributed  equally  between  the  two
 In order to reduce bias and make the trial as  objective  as  possible  the
double-blind technique is sometimes used. In  this  procedure,  neither  the
doctor nor the patients  know  which  of  two  treatments  is  being  given.
Despite such precautions the results of such trials can  be  prejudiced,  so
that rigorous statistical analysis is required.  It  is  obvious  that  many
ethical, not to say legal, considerations arise, and it  is  essential  that
all patients have given their informed consent to be included.  Difficulties
arise when patients are unconscious, mentally confused, or otherwise  unable
to give their  informed  consent.  Children  present  a  special  difficulty
because not all laws agree that parents can legally commit  a  child  to  an
experimental procedure. Trials, and indeed all forms  of  clinical  research
that involve patients, must  often  be  submitted  to  a  committee  set  up
locally to scrutinize each proposal.
 Surgery. In drug research the essential steps are taken by the chemists who
synthesize or isolate new drugs in the laboratory; clinicians  play  only  a
subsidiary part. In developing new surgical  operations  clinicians  play  a
more  important  role,  though  laboratory  scientists  and  others  in  the
background may also contribute largely. Many new operations have  been  made
possible by advances in anesthesia, and these in turn depend upon  engineers
who have devised machines and chemists who have produced  new  drugs.  Other
operations are made possible by  new  materials,  such  as  the  alloys  and
plastics that are used to make .artificial hip and knee joints.
Whenever practicable, new operations are tried on animals  before  they  are
 tried  on  patients.  This  practice  is  particularly  relevant  to  organ
 transplants.         Surgeons          themselvesnot          experimental
 physiologiststransplanted kidneys, livers, and hearts  in  animals  before
 attempting these procedures on patients.  Experiments  on  animals  are  of
 limited value, however, because animals do not suffer from all of the  same
 maladies as do humans.
 Many other developments in modem surgical treatment rest on a firm basis of
experimentation, often first in animals but also in humans; among  them  are
renal dialysis (the artificial kidney), arterial bypass  operations,  embryo
implantation, and exchange transfusions. These treatments are but a  few  of
the more dramatic of a large range of therapeutic  measures  that  have  not
only provided  patients  with  new  therapies  but  also  have  led  to  the
acquisition of new knowledge of how  the  body  works.  Among  the  research
projects of the late 20th century is that  of  gene  transplantation,  which
has the potential of providing cures for cancer and other diseases.

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
 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.