The practice of modern medicine

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

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