The practice of modern medicine

The practice of modern medicine

Contens:

1. Health care and its delivery

2. ORGANIZATION OF HEALTH SERVICES

3. Levels of health care.

4. Costs of health care.

5. ADMINISTRATION OF PRIMARY HEALTH CARE

6. MEDICAL PRACTICE IN. DEVELOPED COUNTRIES

7. Britain.

8. United Stales.

9. Russia.

10. Japan.

11. Other developed countries.

12. MEDICAL PRACTICE IN DEVELOPING COUNTRIES

13. China

14. India.

15. ALTERNATIVE OR COMPLEMENTARY MEDICINE

16. SPECIAL PRACTICES AND FIELDS OF MEDICINE

17. Specialties in medicine.

18. Teaching.

19. Industrial medicine.

20. Family health care.

21. Geriatrics.

22. Public health practice.

23. Military practice.

24. CLINICAL RESEARCH

25. Historical notes.

26. Clinical observation.

27. Drug research.

28. Surgery.

29. SCREENING PROCEDURES

THE PRACTICE OF MODERN MEDICINE

Health care and its delivery

The World Health Organization at its 1978 international, conference held in

the Soviet Union produced the Alma-Ata Health Declaration, which was

designed to serve governments as a basis for planning health care that

would reach people at all levels of society. The declaration reaffirmed

that "health, which is a state of complete physical, mental and social well-

being, and not merely the absence of disease or infirmity, is a fundamental

human rit.nl and that the attainment of the highest possible level of

health is a most important world-wide social goal whose realization

requires the action of many other social and economic sectors in addition

to the health sector." In its widest form the practice of medicine, that is

to say the promotion and care of health, is concerned with this ideal.

ORGANIZATION OF HEALTH SERVICES

"It is generally the goal of most countries to have their health services

organized in such a way to ensure that individuals, families, and

communities obtain the maximum benefit from current knowledge and

technology available for the promotion, maintenance, and restoration of

health. In order to play their part in this process, governments and other

agencies are faced with numerous tasks, including the following: (1) They

must obtain as much information as is possible on the size, extent, and

urgency of their needs; without accurate information, planning can be

misdirected. (2) These needs must then be revised against the resources

likely to be available in terms of money, manpower, and materials;

developing countries may well require external aid to supplement their own

resources. (3) Based on their assessments, countries then need to determine

realistic objectives and draw up plans. (4) Finally, a process of

evaluation needs to be built into the program; the lack of reliable

information and accurate assessment can lead to confusion, waste, and

inefficiency.

Health services of any nature reflect a number "I interrelated

characteristics, among which the most obvious but not necessarily the most

important from a national point of view, is the curative function; that is

to say caring for those already ill. Others include special services that

deal with particular groups (such as children or pregnant women) and with

specific needs such as nutrition or immunization; preventive services, the

protection of the health both of individuals and of communities; health

education; and, as mentioned above, the collection and analysis of

information.

Levels of health care.

In the curative domain there are various forms оf medical practice. They

may be thought of generally as forming a pyramidal structure, with three

tiers representing increasing degrees of specialization and technical

sophistication but catering to diminishing numbers of patients as they are

filtered out of the system at a lower level. Only those patients who

require special attention or treatment should reach the second (advisory)

or third (specialized treatment) tiers where the cost per item of service

becomes increasingly higher. The first level represents primary health

care, or first contact care, or which patients have their initial contact

with the health-care system.

Primary health care is an integral part of a country's health maintenance

system, of which it forms the largest and most important part. As described

in the declaration of Alma-Ata, primary health care should be "based on

practical scientifically sound and socially acceptable methods and

technology made universally accessible to individuals in the community

through their full participation and at a cost that the community and

country can afford to maintain at every stage of then development." Primary

health care in the developed countries is usually the province of a

medically qualified physician; in the developing countries first contact

care is often provided by nonmedically qualified personnel.

The vast majority of patients can be fully dealt with at the primary level.

Those who cannot are referred to the second tier (secondary health care, or

the referral services) for the opinion of a consultant with specialized

knowledge or for X-ray examinations and special tests. Secondary health

care often requires the technology offered by a local or regional hospital.

Increasingly, however, the radiological and laboratory services provided by

hospitals are available directly to the family doctor, thus improving his

service to palings and increasing its range. The third tier of health care

employing specialist services, is offered by institutions such as leaching

hospitals and units devoted to the care of particular groups—women,

children, patients with mental disorders, and so on. The dramatic

differences in the cost of treatment at the various levels is a matter of

particular importance in developing countries, where the cost of treatment

for patients at the primary health-care level is usually only a small

fraction of that at the third level- medical costs at any level in such

countries, however, are usually borne by the government.

Ideally, provision of health care at all levels will be available to all

patients; such health care may be said to be universal. The well-off, both

in relatively wealthy industrialized countries and in the poorer developing

world, may be able to get medical attention from sources they prefer and

can pay for in the private sector. The vast majority of people in most

countries, however, are dependent in various ways upon health services

provided by the state, to which they may contribute comparatively little

or, in the case of poor countries, nothing at all.

Costs of health care. The costs to national economics of providing health

care are considerable and have been growing at a rapidly increasing rate,

especially in countries such as the United States, Germany, and Sweden; the

rise in Britain has been less rapid. This trend has been the cause of major

concerns in both developed and developing countries. Some of this concern

is based upon the lack of any consistent evidence to show that more

spending on health care produces better health. There is a movement in

developing countries to replace the type of organization of health-care

services that evolved during European colonial times with some less

expensive, and for them, more appropriate, health-care system.

In the industrialized world the growing cost of health services has caused

both private and public health-care delivery systems to question current

policies and to seek more economical methods of achieving their goals.

Despite expenditures, health services are not always used effectively by

those who need them, and results can vary widely from community to

community. In Britain, for example, between 1951 and 1971 the death rate

fell by 24 percent in the wealthier sections of the population but by only

half that in the most underprivileged sections of society. The achievement

of good health is reliant upon more than just the quality of health care.

Health entails such factors as good education, safe working conditions, a

favourable environment, amenities in the home, well-integrated social

services, and reasonable standards of living.

In the developing countries. The developing countries differ from one

another culturally, socially, and economically, but what they have in

common is a low average income per person, with large percentages of their

populations living at or below the poverty level. Although most have a

small elite class, living mainly in the cities, the largest part of their

populations live in rural areas. Urban regions in developing and some

developed countries in the mid- and late 20th century have developed

pockets of slums, which are growing because of an influx of rural peoples.

For lack of even the simplest measures, vast numbers of urban and rural

poor die each year of preventable and curable diseases, often associated

with poor hygiene and sanitation, impure water supplies, malnutrition,

vitamin deficiencies, and chronic preventable infections. The effect of

these and other deprivations is reflected by the finding that in the 1980s

the life expectancy at birth for men and women was about one-third less in

Africa than it was in Europe; similarly, infant mortality in Africa was

about eight times greater than in Europe. The extension of primary health-

care services is therefore a high priority in the developing countries.

The developing countries themselves, lacking the proper resources, have

often been unable to generate or implement the plans necessary to provide

required services at the village or urban poor level. It has, however,

become clear that the system of health care that is appropriate for one

country is often unsuitable for another. Research has established that

effective health care is related to the special circumstances of the

individual country, its people, culture, ideology, and economic and natural

resources.

The rising costs of providing health care have influenced a trend,

especially among the developing nations to promote services that employ

less highly trained primary health-care personnel who can be distributed

more widely in order to reach the largest possible proportion of the

community. The principal medical problems to be dealt with in the

developing world include undernutrition, infection, gastrointestinal

disorders, and respiratory complaints. which themselves may be the result

of poverty, ignorance, and poor hygiene. For the most part, these are easy

to identity and to treat. Furthermore, preventive measures are usually

simple and cheap. Neither treatment nor prevention requires extensive

professional training: in most cases they can be dealt with adequately by

the "primary health worker," a term that includes all nonprofessional

health personnel.

In the developed countries. Those concerned with providing health care in

the developed countries face a different set of problems. The diseases so

prevalent in the Third World have, for the most part, been eliminated or

are readily treatable. Many of the adverse environmental conditions and

public health hazards have been conquered. Social services of varying

degrees of adequacy have been provided. Public funds can be called upon to

support the cost of medical care, and there are a variety of private

insurance plans available to the consumer. Nevertheless, the funds that a

government can devote to health care are limited and the cost of modern

medicine continues to increase thus putting adequate medical services

beyond the reach of many. Adding to the expense of modern medical practices

is the increasing demand for greater funding of health education and

preventive measures specifically directed toward the poor.

ADMINISTRATION OF PRIMARY HEALTH CARE

In many parts of the world, particularly in developing countries, people

get their primary health care, or first-contact care, where available at

all, from nonmedically qualified personnel; these cadres of medical

auxiliaries are being trained in increasing numbers to meet overwhelming

needs among rapidly growing populations. Even among the comparatively

wealthy countries of the world, containing in all a much smaller percentage

of the world's population, escalation in the costs of health services and

in the cost of training a physician has precipitated some movement toward

reappraisal of the role of the medical doctor in the delivery of first-

contact care.

In advanced industrial countries, however, it is usually a trained

physician who is called upon to provide the first-contact care. The patient

seeking first-contact care can go either to a general practitioner or turn

directly to a specialist. Which is the wisest choice has become a subject

of some controversy. The general practitioner, however, is becoming rather

rare in some developed countries. In countries where he does still exist,

he is being increasingly observed as an obsolescent figure, because

medicine covers an immense, rapidly changing, and complex field of which no

physician can possibly master more than a small fraction. The very concept

of the general practitioner, it is thus argued, may be absurd.

The obvious alternative to general practice is the direct access of a

patient to a specialist. If a patient has problems with vision, he goes to

an eye specialist, and if he has a pain in his chest (which he fears is due

to his heart), he goes to a heart specialist. One objection to this plan is

that the patient often cannot know which organ is responsible for his

symptoms, and the most careful physician, after doing many investigations,

may remain uncertain as to the cause. Breathlessness—a common symptom—may

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

Another common symptom is general malaise—feeling run-down or always tired;

others are headache, chronic low backache, rheumatism, abdominal

discomfort, poor appetite, and constipation. Some patients may also be

overtly anxious or depressed. Among the most subtle medical skills is the

ability to assess people with such symptoms and to distinguish between

symptoms that are caused predominantly by emotional upset and those that

are predominantly of bodily origin. A specialist may be capable of such a

general assessment, but, often, with emphasis on his own subject, he fails

at this point. The generalist with his broader training is often the better

choice for a first diagnosis, with referral to a specialist as the next

option,

It is often felt that there are also practical advantages for the patient

in having his own doctor, who knows about his background, who has seen him

through various illnesses, and who has often looked after his family as

well. This personal physician, often a generalist, is in the best position

to decide when the patient should be referred to a consultant.

The advantages of general practice and specialization are combined when the

physician of first contact is a pediatrician. Although he sees only

children and thus acquires a special knowledge of childhood maladies, he

remains a generalist who looks at the whole patient. Another combination of

general practice and specialization is represented by group practice, the

members of which partially or fully specialize. One or more may be general

practitioners, and one may be a surgeon, a second an obstetrician, a third

a pediatrician, and a fourth an internist. In isolated communities group

practice may be a satisfactory compromise, but in urban regions, where

nearly everyone can be sent quickly to a hospital, the specialist surgeon

working in a fully equipped hospital can usually provide better treatment

than a general practitioner surgeon in a small clinic hospital.

MEDICAL PRACTICE IN. DEVELOPED COUNTRIES

Britain. Before 1948, general practitioners in Britain settled where they

could make a living. Patients fell into two main groups: weekly wage

earners, who were compulsorily insured, were on a doctor's "panel" and were

given free medical attention (for which the doctor was paid quarterly by

the government); most of the remainder paid the doctor a fee for service at

the time of the illness. In 1948 the National Health Service began

operation. Under its provisions, everyone is entitled to free medical

attention with a general practitioner with whom he is registered. Though

general practitioners in the National Health Service are not debarred from

also having private patients, these must be people who are not registered

with them under the National Health Service. Any physician is free to work

as a general practitioner entirely independent of the National Health

Service, though there are few who do so. Almost the entire population is

registered with a National Health Service general practitioner, and the

vast majority automatically sees this physician, or one of his partners,

when they require medical attention. A few people, mostly wealthy, while

registered with a National Health Service general practitioner, regularly

see another physician privately; and a few may occasionally seek a private

consultation because they are dissatisfied with their National Health

Service physician.

A general practitioner under the National Health Service remains an

independent contractor, paid by a capitation fee; that is, according to the

number of people registered with him. He may work entirely from his own

office, and he provides and pays his own receptionist, secretary, and other

ancillary staff. Most general practitioners have one or more partners and

work more and more in premises built for the purpose. Some of these

structures are erected by the physicians themselves, but many are provided

by the local 'authority, me physicians paying rent for using them. Health

centres, in which groups of general practitioners work have become common.

In Britain only a small minority of general practitioners can admit

patients to a hospital and look after them personally. Most of this

minority are in country districts, where, before the days of the National

Health Service, there were cottage hospitals run by general practitioners;

many of these hospitals continued to function in a similar manner. All

general practitioners use such hospital facilities as X-ray departments and

laboratories, and many general practitioners work in hospitals in emergency

rooms (casualty departments) or as clinical assistants to consultants, or

specialists.

General practitioners are spread more evenly over the country than

formerly, when there were many in the richer areas and few in the

industrial towns. The maximum allowed list of National Health Service

patients per doctor is 3.500; the average is about 2.500. Patients have

free choice of the physician with whom they register, with the proviso that

they cannot be accepted by one who already has a full list and that a

physician can refuse to accept them (though such refusals are rare). In

remote rural places there may be only one physician within a reasonable

distance.

Until the mid-20th century it was not unusual for the doctor in Britain to

visit patients in their own homes. A general practitioner might make 15 or

20 such house calls in a day. as well as seeing patients in his office or

"surgery," often in the evenings. This enabled him to become a family

doctor in fact as well as in name. In modern practice, however, a home

visit is quite exceptional and is paid only to the severely disabled or

seriously ill when other recourses are ruled out. All patients are normally

required to go to the doctor.

It has also become unusual for a personal doctor to be available during

weekends or holidays. His place may be taken by one of his partners in a

group practice, a provision that is reasonably satisfactory. General

practitioners, however, may now use one of several commercial deputizing

services that employs young doctors to he on call. Although some of these

young doctors may he well experienced, patients do not generally appreciate

this kind of arrangement.

United Stales. Whereas in Britain the doctor of first contact is regularly

a general practitioner, in the United States the nature of first-contact

care is less consistent. General practice in the United States has been in

a slate of decline in the second half of the 20th century especially in

metropolitan areas. The general practitioner, however, is being replaced to

some degree by the growing field of family practice. In 1969 family

practice was recognized as a medical specialty after the American Academy

of General Practice (now the American Academy of Family Physicians) and the

American Medical Association created the American Board of General (now

Family) Practice. Since that time the field has become one of the larger

medical specialties in the United States. The family physicians were the

first group of medical specialists in the

United States for whom recertification was required.

Theie is no national health service, as such, in the United Stales. Most

physicians in the country have traditionally been in some form of private

practice, whether seeing patients in their own offices. clinics, medical

centres, or another type of facility and regardless of the patients'

income. Doctors are usually compensated by such state and federally

supported agencies as Medicaid (for treating the poor) and Medicare (for

treating the elderly); not all doctors, however, accept poor patients.

There are also some state-supported clinics and hospitals where the poor

and elderly may receive free or low-cost treatment, and some doctors devote

a small percentage of their time to treatment of the indigent. Veterans may

receive free treatment at Veterans Administration hospitals, and the

federal government through its Indian Health Service provides medical

services to American Indians and Alaskan natives, sometimes using trained

auxiliaries for first-contact care.

In the rural United States first-contact care is likely to come from a

generalist I he middle- and upper-income groups living in urban areas,

however, have access to a larger number of primary medical care options.

Children are often taken to pediatricians, who may oversee the child's

health needs until adulthood. Adults frequently make their initial contact

with an internist, whose field is mainly that of medical (as opposed to

surgical) illnesses; the internist often becomes the family physician.

Other adults choose to go directly to physicians with narrower specialties,

including dermatologists, allergists, gynecologists, orthopedists, and

ophthalmologists.

Patients in the United States may also choose to be treated by doctors of

osteopathy. These doctors are fully qualified, but they make up only a

small percentage of the country's physicians. They may also branch off into

specialties, hut general practice is much more common in their group than

among M.D.'s.

It used to be more common in the United States for physicians providing

primary care to work independently, providing their own equipment and

paying their own ancillary staff. In smaller cities they mostly had full

hospital privileges, but in larger cities these privileges were more likely

to be restricted. Physicians, often sharing the same specialties, are

increasingly entering into group associations, where the expenses of office

space, staff, and equipment may be shared; such associations may work out

of suites of offices, clinics, or medical centres. The increasing

competition and risks of private practice have caused many physicians to

join Health Maintenance Organizations (HMOs), which provide comprehensive

medical. care and hospital care on a prepaid basis. Thе cost savings to

patient's are considerable, but they must use only the HMO doctors and

facilities. HMOs stress preventive medicine and out-patient treatment as

opposed to hospitalization as a means of reducing costs, a policy that has

caused an increased number of empty hospital beds in the United States.

While the number of doctors per 100,000 population in the United States has

been steadily increasing, there has been a trend among physicians toward

the use of trained medical personnel to handle some of the basic services

normally performed by the doctor. So-called physician extender services are

commonly divided into nurse practitioners and physician's assistants, both

of whom provide similar ancillary services for the general practitioner or

specialist. Such personnel do not replace the doctor. Almost all American

physicians have systems for taking each other's calls when they become

unavailable. House calls in the United Stales, as in Britain, have become

exceedingly rare.

Russia. In Russia general practitioners are prevalent in the thinly

populated rural areas. Pediatricians deal with children up to about age 15.

Internists look after the medical ills of adults, and occupational

physicians deal with the workers, sharing care with internists.

Teams of physicians with experience in varying specialties work from

polyclinics or outpatient units, where many types of diseases are treated.

Small towns usually have one polyclinic to serve all purposes. Large cities

commonly have separate polyclinics for children and adults, as well as

clinics with specializations such as women's health care, mental illnesses,

and sexually transmitted diseases. Polyclinics usually have X-ray apparatus

and facilities for examination of tissue specimens, facilities associated

with the departments of the district hospital. Beginning in the late 1970s

was a trend toward the development of more large, multipurpose treatment

centres, first-aid hospitals, and specialized medicine and health care

centres.

Home visits have traditionally been common, and much of the physician's

time is spent in performing routine checkups for preventive purposes. Some

patients in sparsely populated rural areas may be seen first by feldshers

(auxiliary health workers), nurses, or midwives who work under the

supervision of a polyclinic or hospital physician. The feldsher was once a

lower-grade physician in the army or peasant communities, but feldshers are

now regarded as paramedical workers.

Japan. In Japan, with less rigid legal restriction of the sale of

pharmaceuticals than in the West, there was formerly a strong tradition of

self-medication and self-treatment. This was modified in 1961 by the

institution of health insurance programs that covered a large proportion of

the population; there was then a great increase in visits to the outpatient

clinics of hospitals and to private clinics and individual physicians.

When Japan shifted from traditional Chinese medicine with the adoption of

Western medical practices in the 1870s. Germany became the chief model. As

a result of German influence and of their own traditions, Japanese

physicians tended to prefer professorial status and scholarly research

opportunities at the universities or positions in the national or

prefectural hospitals to private practice. There were some pioneering

physicians, however, who brought medical care to the ordinary people.

Physicians in Japan have tended to cluster in the urban areas. The Medical

Service Law of 1963 was amended to empower the Ministry of Health and

Welfare to control the planning and distribution of future public and

nonprofit medical facilities, partly to redress the urban-rural imbalance.

Meanwhile, mobile services were expanded.

The influx of patients into hospitals and private clinics after the passage

of the national health insurance acts of 1961 had, as one effect, a severe

reduction in the amount of time available for any one patient. Perhaps in

reaction to this situation, there has been a modest resurgence in the

popularity of traditional Chinese medicine, with its leisurely interview,

its dependence on herbal and other "natural" medicines, and its other

traditional diagnostic and therapeutic practices. The rapid aging of the

Japanese population as a result of the sharply decreasing death rate and

birth rate has created an urgent need for expanded health care services /or

the elderly. There has also been an increasing need for centres to treat

health problems resulting from environmental causes.

Other developed countries. On the continent of Europe there are great

differences both within single countries and between countries in the kinds

of first-contact medical care. General practice, while declining in Europe

as elsewhere, is still rather common even in some large cities, as well as

in remote country areas.

In The Netherlands, departments of general practice are administered by

general practitioners in all the medical schools—an exceptional state of

affairs—and general practice flourishes. In the larger cities of Denmark,

general practice on an individual basis is usual and popular, because the

physician works only during office hours. In addition, there is a duty

doctor service for nights and weekends. In the cities of Sweden, primary

care is given by specialists. In the remote regions of northern Sweden,

district doctors act as general practitioners to patients spread over huge

areas; the district doctors delegate much of their home visiting to nurses.

In France there are still general practitioners, but their number is

declining. Many medical practitioners advertise themselves directly to the

public as specialists in internal medicine, ophthalmologists,

gynecologists, and other kinds of specialists. Even when patients have a

general practitioner, they may still go directly to a specialist. Attempts

to stem the decline in general practice are being made hy the development

of group practice and of small rural hospitals equipped to deal with less

serious illnesses, where general practitioners can look after their

patients.

Although Israel has a high ratio of physicians to population, there is a

shortage of general practitioners, and only in rural areas is general

practice common. In the towns many people go directly to pediatricians,

gynecologists, and other specialists, but there has been a reaction against

this direct access to the specialist. More general practitioners have been

trained, and the Israel Medical Association has recommended that no patient

should be referred to a specialist except by the family physician or on

instructions given by the family nurse. At Tel Aviv University there is a

department of family medicine. In some newly developing areas, where the

doctor shortage is greatest, there are medical centres at which all

patients are initially interviewed by a nurse. The nurse may deal with many

minor ailments, thus freeing the physician to treat the more seriously ill.

Nearly half the medical doctors in Australia are general practitioners—a

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

elsewhere, their numbers are declining. They tend to do far more for their

patients than in Britain, many performing such operations as removal of the

appendix, gallbladder, or uterus, operations that elsewhere would be

carried out by a specialist surgeon. Group practices are common.

MEDICAL PRACTICE IN DEVELOPING COUNTRIES

China. Health services in China since the Cultural Revolution have been

characterized by decentralization and dependence on personnel chosen

locally and trained for short periods. Emphasis is given to selfless

motivation, self-reliance, and to the involvement of everyone in the

community. Campaigns stressing the importance of preventive measures and

their implementation have served to create new social attitudes as well as

to break down divisions between different categories of health workers.

Health care is regarded as a local matter that should not require the

intervention of any higher authority; it is based upon a highly organized

and well-disciplined system that is egalitarian rather than hierarchical,

as in Western societies, and which is well suited to the rural areas where

about two-thirds of the population live. In the large and crowded cities an

important constituent of the health-care system is the residents'

committees, each for a population of 1,000 to 5,000 people. Care is

provided by part-time personnel with periodic visits by a doctor. A number

of residents' committees are grouped together into neighbourhoods of some

50,000 people where there are clinics and general hospitals staffed by

doctors as well as health auxiliaries trained in both traditional and

Westernized medicine. Specialized care is provided at the district level

(over 100,000 people), in district hospitals and in epidemic and preventive

medicine centres. In many rural districts people's communes have organized

cooperative medical services that provide primary care for a small annual

fee.

Throughout China the value of traditional medicine is stressed, especially

in the rural areas. All medical schools are encouraged to teach traditional

medicine as part of their curriculum, and efforts are made to link colleges

of Chinese medicine with Western-type medical schools. Medical education is

of shorter duration than it is in Europe, and there is greater emphasis on

practical work. Students spend part of their time away from the medical

school working in factories or in communes; they are encouraged to question

what they are taught and to participate in the educational process at all

stages. One well-known form of traditional medicine is acupuncture, which

is used as a therapeutic and pain-relieving technique; requiring the

insertion of brass-handled needles at various points on the body,

acupuncture has become quite prominent as a form of anesthesia.

The vast number of nonmedically qualified health staff, upon whom the

health-care system greatly depends, includes both full-time and part-time

workers. The latter include so-called barefoot doctors, who work mainly in

rural areas, worker doctors in factories, and medical workers in

residential communities. None of these groups is medically qualified. They

have had only a three-month period of formal training, part of which is

done in a hospital, fairly evenly divided between theoretical and practical

work. This is followed by a varying period of on-the-job experience under

supervision.

India. Ayurvedic medicine is an example of a well-organized system of

traditional health care, both preventive and curative, that is widely

practiced in parts of Asia. Ayurvedic medicine has a long tradition behind

it, having originated in India perhaps as long as 3.000 years ago. It is

still a favoured form of health care in large parts of the Eastern world,

especially in India, where a large percentage of the population use this

system exclusively or combined with modern medicine. The Indian Medical

Council was set up in 1971 by the Indian government to establish

maintenance of standards for undergraduate and postgraduate education. It

establishes suitable qualifications in Indian medicine and recognizes

various forms of traditional practice including Ayurvedic. Unani. and

Siddha. Projects have been undertaken to integrate the indigenous Indian

and Western forms of medicine. Most Ayurvedic practitioners work in rural

areas, providing health care to at least 500,000.000 people in India alone.

They therefore represent a major force for primary health care, and their

training and deployment are important to the government of India.

Like scientific medicine, Ayurvedic medicine has both preventive and

curative aspects. The preventive component emphasizes the need for a strict

code of personal and social hygiene, the details of which depend upon

individual, climatic, and environmental needs. Rodilv exercises, the use of

herbal preparations, and Yoga form a part of the remedial measures. The

curative aspects of Avurvcdic medicine involves the use of herbal

medicines, 'external preparations, physiotherapy, and diet. It is a

principle of Ayurvedic medicini. that the preventive and therapeutic

measures be adapted to the personal requirements of each patient.

Other developing countries. A main goal of the World Health Organization

(WHO), as expressed in the Alma-Ata Declaration of 1978, is to provide to

all the citizens of the world a level of health that will allow them to

lead socially and economically productive lives by the year 2000. By the

late 1980s, however, vast disparities in health care still existed between

the rich and poor countries of the world. In developing countries such as

Ethiopia, Guinea, Mali, and Mozambique, for instance, governments in the

late 1980s spent less than $5 per person per year on public health, while

in most western European countries several hundred dollars per year was

spent on each person. The disproportion of the number of physicians

available between developing and developed countries is similarly wide.

Along with the shortage of physicians, there is a shortage of everything

else needed to provide medical care—of equipment, drugs, and suitable

buildings, and of nurses, technicians, and all other grades of staff, whose

presence is taken for granted in the affluent societies. Yet there are

greater percentages of sick in the poor countries than in the rich

countries. In the poor countries a high proportion of people are young, and

all are liable to many infections, including tuberculosis, syphilis,

typhon). and cholera (which, with the possible exception of syphilis, are

now rare in the rich countries), and also malaria, yaws. worm infestations,

and many other conditions occurring primarily in the warmer climates.

Nearly all of these infections respond to the antibiotics and other drugs

that have been discovered since the 1920s. There is also much malnutrition

and anemia, which can be cured if funding is available. There is a

prevalence of disorders remediable by surgery. Preventive medicine can

ensure clean water supplies, destroy insects that carry infections, teach

hygiene, and show how to make the best use of resources.

In most poor countries there are a few people, usually living in the

cities, who can afford to pay for medical care and in a free market system

the physicians lend to go where they can make the best living; this

situation causes the doctor-patient ratio to be much higher in the towns

than in country districts. A physician in Bombay or in Rio de Janeiro, for

example, may have equipment as lavish as that of a physician in the United

States and can earn an excellent income. The poor, however, both in the

cities and in the country, can gel medical attention only if it is paid for

by the state, by some supranational body, or by a mission or other

charitable organization. Moreover, the quality of the care they receive is

often poor, and in remote regions it may be lacking altogether. In

practice, hospitals run by a mission may cooperate closely with stale-run

health centres.

Because physicians are scarce, their skills must be used to best advantage,

and much of the work normally done by physicians in the rich countries has

to be delegated to auxiliaries or nurses, who have to diagnose the common

conditions, give treatment, take blood samples, help with operations,

supply simple posters containing health advice, and carry out other tasks.

In such places the doctor has lime only to perform major operations and

deal with the more difficult medical problems. People are treated as far as

possible on an outpatient basis from health centres housed in simple

buildings; few can travel except on foot, and, if they are more than a few

miles from a health centre, they tend not to go there. Health centres also

may be used for health education.

Although primary health-care service diners from country to country, that

developed in Tanzania is representative of many that have been devised in

largely rural developing countries. The most important feature of the

Tanzanian rural health service is the rural health centre, which, with its

related dispensaries, is intended to provide comprehensive health services

for the community. The staff is headed by the assistant medical officer and

the medical assistant. The assistant medical officer has at least lour

years of experience, which is then followed by further training for 18

months. He is not a doctor but serves to bridge the gap between medical

assistant and physician. The medical assistant has three years of general

medical education. The work of the rural health centres and dispensaries is

mainly of three kinds: diagnosis and treatment, maternal and child health,

and environmental health. The main categories of primary health workers

also include medical aids, maternal and child health aids, and health

auxiliaries. Nurses and midwives form another category of worker. In the

villages there are village health posts staffed by village medical helpers

working under supervision from the rural health centre.

In some primitive elements of the societies of developing countries, and of

some developed countries, there exists the belief that illness comes from

the displeasure of ancestral gods and evil spirits, from the malign

influence of evil disposed persons, or from natural phenomena that can

neither he forecast nor controlled. To deal with such causes there are many

varieties of indigenous healers who practice elaborate rituals on behalf of

both the physically ill and the mentally afflicled. If it is understood

that such beliefs, and other forms of shamanism, may provide a basis upon

which health care can be based, then primary health care may he said to

exist almost everywhere. It is not only easily available but also readily

acceptable, and often preferred, to more rational methods of diagnosis and

treatment. Although such methods may sometimes be harmful, they may often

be effective, especially where the cause is psychosomatic. Other patients,

however, may suffer from a disease for which there is a cure in modern

medicine.

In order to improve the coverage of primary health-care services and lo

spread more widely some of the benefits of Wesiern medicine, attempts have

sometimes been made to tun.) a means of cooperation, or even integration,

between traditional and modern medicine (see above India). In Aluca, for

example, some such attempts are officially sponsored by ministries of

health, state governments, universities, and the like, and they have the

approval of WHO, which often lakes the lead in this activity. In view,

however, of the historical relationships between these two systems of

medicine, their different basic concepts, and the fuel that their methods

cannot readily be combined, successful merging has been limited.

ALTERNATIVE OR COMPLEMENTARY MEDICINE

Persons dissatisfied with the methods of modern medicine or with its

results sometimes seek help from those professing expertise in other, less

conventional, and sometimes controversial, forms of health care. Such

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