Ðåôåðàò: The practice of modern medicine
Contens:
1. Health care and its
delivery
2. ORGANIZATION OF HEALTH
SERVICES
3. Levels of health care.
4. Costs of health care.
5. ADMINISTRATION OF PRIMARY
HEALTH CARE
6. MEDICAL PRACTICE IN.
DEVELOPED COUNTRIES
7. Britain.
8. United Stales.
9. Russia.
10. Japan.
11. Other developed
countries.
12. MEDICAL PRACTICE IN
DEVELOPING COUNTRIES
13. China
14. India.
15. ALTERNATIVE OR COMPLEMENTARY
MEDICINE
16. SPECIAL PRACTICES AND FIELDS OF
MEDICINE
17. Specialties in medicine.
18. Teaching.
19. Industrial medicine.
20. Family health care.
21. Geriatrics.
22. Public health practice.
23. Military practice.
24. CLINICAL RESEARCH
25. Historical notes.
26. Clinical observation.
27. Drug research.
28. Surgery.
29. SCREENING PROCEDURES
THE PRACTICE OF MODERN MEDICINE
Health care and its delivery
The World Health
Organization at its 1978 international, conference held in the Soviet Union
produced the Alma-Ata Health Declaration, which was designed to serve governments
as a basis for planning health care that would reach people at all levels of
society. The declaration reaffirmed that "health, which is a state of
complete physical, mental and social well-being, and not merely the absence of
disease or infirmity, is a fundamental human rit.nl and that the attainment of
the highest possible level of health is a most important world-wide social goal
whose realization requires the action of many other social and economic sectors
in addition to the health sector." In its widest form the practice of
medicine, that is to say the promotion and care of health, is concerned with
this ideal.
ORGANIZATION OF
HEALTH SERVICES
"It is generally the goal
of most countries to have their health services organized in such a way to
ensure that individuals, families, and communities obtain the maximum benefit
from current knowledge and technology available for the promotion, maintenance,
and restoration of health. In order to play their part in this process,
governments and other agencies are faced with numerous tasks, including the
following: (1) They must obtain as much information as is possible on the size,
extent, and urgency of their needs; without accurate information, planning can
be misdirected. (2) These needs must then be revised against the resources
likely to be available in terms of money, manpower, and materials; developing
countries may well require external aid to supplement their own resources. (3)
Based on their assessments, countries then need to determine realistic
objectives and draw up plans. (4) Finally, a process of evaluation needs to be
built into the program; the lack of reliable information and accurate
assessment can lead to confusion, waste, and inefficiency.
Health services of
any nature reflect a number "I interrelated characteristics, among which
the most obvious but not necessarily the most important from a national point
of view, is the curative function; that is to say caring for those already ill.
Others include special services that deal with particular groups (such as
children or pregnant women) and with specific needs such as nutrition or
immunization; preventive services, the protection of the health both of
individuals and of communities; health education; and, as mentioned above, the
collection and analysis of information.
Levels of health care.
In the curative domain there are
various forms 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.