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 inthe Soviet Union produced the Alma-Ata Health Declaration, which wasdesigned to serve governments as a basis for planning health care thatwould reach people at all levels of society. The declaration reaffirmedthat "health, which is a state of complete physical, mental and social well -being, and not merely the absence of disease or infirmity, is a fundamentalhuman rit.nl and that the attainment of the highest possible level ofhealth is a most important world-wide social goal whose realizationrequires the action of many other social and economic sectors in additionto the health sector. "In its widest form the practice of medicine, that isto 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 servicesorganized in such a way to ensure that individuals, families, andcommunities obtain the maximum benefit from current knowledge andtechnology available for the promotion, maintenance, and restoration ofhealth. In order to play their part in this process, governments and otheragencies are faced with numerous tasks, including the following: (1) Theymust obtain as much information as is possible on the size, extent, andurgency of their needs; without accurate information, planning can bemisdirected. (2) These needs must then be revised against the resourceslikely to be available in terms of money, manpower, and materials;developing countries may well require external aid to supplement their ownresources. (3) Based on their assessments, countries then need to determinerealistic objectives and draw up plans. (4) Finally, a process ofevaluation needs to be built into the program; the lack of reliableinformation and accurate assessment can lead to confusion, waste, andinefficiency.
Health services of any nature reflect a number "I interrelatedcharacteristics, among which the most obvious but not necessarily the mostimportant from a national point of view, is the curative function; that isto say caring for those already ill. Others include special services thatdeal with particular groups (such as children or pregnant women) and withspecific needs such as nutrition or immunization; preventive services, theprotection of the health both of individuals and of communities; healtheducation; and, as mentioned above, the collection and analysis ofinformation.
Levels of health care.
In the curative domain there are various forms оf medical practice. Theymay be thought of generally as forming a pyramidal structure, with threetiers representing increasing degrees of specialization and technicalsophistication but catering to diminishing numbers of patients as they arefiltered out of the system at a lower level. Only those patients whorequire special attention or treatment should reach the second (advisory)or third (specialized treatment) tiers where the cost per item of servicebecomes increasingly higher. The first level represents primary healthcare, or first contact care, or which patients have their initial contactwith the health-care system.
Primary health care is an integral part of a country's health maintenancesystem, of which it forms the largest and most important part. As describedin the declaration of Alma-Ata, primary health care should be "based onpractical scientifically sound and socially acceptable methods andtechnology made universally accessible to individuals in the communitythrough their full participation and at a cost that the community andcountry can afford to maintain at every stage of then development. "Primaryhealth care in the developed countries is usually the province of amedically qualified physician; in the developing countries first contactcare 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, orthe referral services) for the opinion of a consultant with specializedknowledge or for X-ray examinations and special tests. Secondary healthcare often requires the technology offered by a local or regional hospital.
Increasingly, however, the radiological and laboratory services provided byhospitals are available directly to the family doctor, thus improving hisservice to palings and increasing its range. The third tier of health careemploying specialist services, is offered by institutions such as leachinghospitals and units devoted to the care of particular groups-women,children, patients with mental disorders, and so on. The dramaticdifferences in the cost of treatment at the various levels is a matter ofparticular importance in developing countries, where the cost of treatmentfor patients at the primary health-care level is usually only a smallfraction of that at the third level-medical costs at any level in suchcountries, however, are usually borne by the government.
Ideally, provision of health care at all levels will be available to allpatients; such health care may be said to be universal. The well-off, bothin relatively wealthy industrialized countries and in the poorer developingworld, may be able to get medical attention from sources they prefer andcan pay for in the private sector. The vast majority of people in mostcountries, however, are dependent in various ways upon health servicesprovided by the state, to which they may contribute comparatively littleor, in the case of poor countries, nothing at all.
Costs of health care. The costs to national economics of providing healthcare are considerable and have been growing at a rapidly increasing rate,especially in countries such as the United States, Germany, and Sweden; therise in Britain has been less rapid. This trend has been the cause of majorconcerns in both developed and developing countries. Some of this concernis based upon the lack of any consistent evidence to show that morespending on health care produces better health. There is a movement indeveloping countries to replace the type of organization of health-careservices that evolved during European colonial times with some lessexpensive, and for them, more appropriate, health-care system.
In the industrialized world the growing cost of health services has causedboth private and public health-care delivery systems to question currentpolicies and to seek more economical methods of achieving their goals.
Despite expenditures, health services are not always used effectively bythose who need them, and results can vary widely from community tocommunity. In Britain, for example, between 1951 and 1971 the death ratefell by 24 percent in the wealthier sections of the population but by onlyhalf that in the most underprivileged sections of society. The achievementof good health is reliant upon more than just the quality of health care.
Health entails such factors as good education, safe working conditions, afavourable environment, amenities in the home, well-integrated socialservices, and reasonable standards of living.
In the developing countries. The developing countries differ from oneanother culturally, socially, and economically, but what they have incommon is a low average income per person, with large percentages of theirpopulations living at or below the poverty level. Although most have asmall elite class, living mainly in the cities, the largest part of theirpopulations live in rural areas. Urban regions in developing and somedeveloped countries in the mid-and late 20th century have developedpockets of slums, which are growing because of an influx of rural peoples.
For lack of even the simplest measures, vast numbers of urban and ruralpoor die each year of preventable and curable diseases, often associatedwith poor hygiene and sanitation, impure water supplies, malnutrition,vitamin deficiencies, and chronic preventable infections. The effect ofthese and other deprivations is reflected by the finding that in the 1980sthe 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 wasabout 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, haveoften been unable to generate or implement the plans necessary to providerequired services at the village or urban poor level. It has, however,become clear that the system of health care that is appropriate for onecountry is often unsuitable for another. Research has established thateffective health care is related to the special circumstances of theindividual country, its people, culture, ideology, and economic and naturalresources.
The rising costs of providing health care have influenced a trend,especially among the developing nations to promote services that employless highly trained primary health-care personnel who can be distributedmore widely in order to reach the largest possible proportion of thecommunity. The principal medical problems to be dealt with in thedeveloping world include undernutrition, infection, gastrointestinaldisorders, and respiratory complaints. which themselves may be the resultof poverty, ignorance, and poor hygiene. For the most part, these are easyto identity and to treat. Furthermore, preventive measures are usuallysimple and cheap. Neither treatment nor prevention requires extensiveprofessional training: in most cases they can be dealt with adequately bythe "primary health worker," a term that includes all nonprofessionalhealth personnel.
In the developed countries. Those concerned with providing health care inthe developed countries face a different set of problems. The diseases soprevalent in the Third World have, for the most part, been eliminated orare readily treatable. Many of the adverse environmental conditions andpublic health hazards have been conquered. Social services of varyingdegrees of adequacy have been provided. Public funds can be called upon tosupport the cost of medical care, and there are a variety of privateinsurance plans available to the consumer. Nevertheless, the funds that agovernment can devote to health care are limited and the cost of modernmedicine continues to increase thus putting adequate medical servicesbeyond the reach of many. Adding to the expense of modern medical practicesis the increasing demand for greater funding of health education andpreventive measures specifically directed toward the poor.

ADMINISTRATION OF PRIMARY HEALTH CARE
In many parts of the world, particularly in developing countries, peopleget their primary health care, or first-contact care, where available atall, from nonmedically qualified personnel; these cadres of medicalauxiliaries are being trained in increasing numbers to meet overwhelmingneeds among rapidly growing populations. Even among the comparativelywealthy countries of the world, containing in all a much smaller percentageof the world's population, escalation in the costs of health services andin the cost of training a physician has precipitated some movement towardreappraisal of the role of the medical doctor in the delivery of first -contact care.
In advanced industrial countries, however, it is usually a trainedphysician who is called upon to provide the first-contact care. The patientseeking first-contact care can go either to a general practitioner or turndirectly to a specialist. Which is the wisest choice has become a subjectof some controversy. The general practitioner, however, is becoming ratherrare in some developed countries. In countries where he does still exist,he is being increasingly observed as an obsolescent figure, becausemedicine covers an immense, rapidly changing, and complex field of which nophysician can possibly master more than a small fraction. The very conceptof the general practitioner, it is thus argued, may be absurd.
The obvious alternative to general practice is the direct access of apatient to a specialist. If a patient has problems with vision, he goes toan eye specialist, and if he has a pain in his chest (which he fears is dueto his heart), he goes to a heart specialist. One objection to this plan isthat the patient often cannot know which organ is responsible for hissymptoms, and the most careful physician, after doing many investigations,may remain uncertain as to the cause. Breathlessness-a common symptom-maybe 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, abdominaldiscomfort, poor appetite, and constipation. Some patients may also beovertly anxious or depressed. Among the most subtle medical skills is theability to assess people with such symptoms and to distinguish betweensymptoms that are caused predominantly by emotional upset and those thatare predominantly of bodily origin. A specialist may be capable of such ageneral assessment, but, often, with emphasis on his own subject, he failsat this point. The generalist with his broader training is often the betterchoice for a first diagnosis, with referral to a specialist as the nextoption,
It is often felt that there are also practical advantages for the patientin having his own doctor, who knows about his background, who has seen himthrough various illnesses, and who has often looked after his family aswell. This personal physician, often a generalist, is in the best positionto decide when the patient should be referred to a consultant.
The advantages of general practice and specialization are combined when thephysician of first contact is a pediatrician. Although he sees onlychildren and thus acquires a special knowledge of childhood maladies, heremains a generalist who looks at the whole patient. Another combination ofgeneral practice and specialization is represented by group practice, themembers of which partially or fully specialize. One or more may be generalpractitioners, and one may be a surgeon, a second an obstetrician, a thirda pediatrician, and a fourth an internist. In isolated communities grouppractice may be a satisfactory compromise, but in urban regions, wherenearly everyone can be sent quickly to a hospital, the specialist surgeonworking in a fully equipped hospital can usually provide better treatmentthan a general practitioner surgeon in a small clinic hospital.

MEDICAL PRACTICE IN. DEVELOPED COUNTRIES
Britain. Before 1948, general practitioners in Britain settled where theycould make a living. Patients fell into two main groups: weekly wageearners, who were compulsorily insured, were on a doctor's "panel" and weregiven free medical attention (for which the doctor was paid quarterly bythe government); most of the remainder paid the doctor a fee for service atthe time of the illness. In 1948 the National Health Service beganoperation. Under its provisions, everyone is entitled to free medicalattention with a general practitioner with whom he is registered. Thoughgeneral practitioners in the National Health Service are not debarred fromalso having private patients, these must be people who are not registeredwith them under the National Health Service. Any physician is free to workas a general practitioner entirely independent of the National Health
Service, though there are few who do so. Almost the entire population isregistered with a National Health Service general practitioner, and thevast majority automatically sees this physician, or one of his partners,when they require medical attention. A few people, mostly wealthy, whileregistered with a National Health Service general practitioner, regularlysee another physician privately; and a few may occasionally seek a privateconsultation because they are dissatisfied with their National Health
Service physician.
A general practitioner under the National Health Service remains anindependent contractor, paid by a capitation fee; that is, according to thenumber of people registered with him. He may work entirely from his ownoffice, and he provides and pays his own receptionist, secretary, and otherancillary staff. Most general practitioners have one or more partners andwork more and more in premises built for the purpose. Some of thesestructures are erected by the physicians themselves, but many are providedby the local 'authority, me physicians paying rent for using them. Healthcentres, in which groups of general practitioners work have become common.
In Britain only a small minority of general practitioners can admitpatients to a hospital and look after them personally. Most of thisminority 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. Allgeneral practitioners use such hospital facilities as X-ray departments andlaboratories, and many general practitioners work in hospitals in emergencyrooms (casualty departments) or as clinical assistants to consultants, orspecialists.
General practitioners are spread more evenly over the country thanformerly, when there were many in the richer areas and few in theindustrial towns. The maximum allowed list of National Health Servicepatients per doctor is 3.500; the average is about 2.500. Patients havefree choice of the physician with whom they register, with the proviso thatthey cannot be accepted by one who already has a full list and that aphysician can refuse to accept them (though such refusals are rare). Inremote rural places there may be only one physician within a reasonabledistance.
Until the mid-20th century it was not unusual for the doctor in Britain tovisit 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 familydoctor in fact as well as in name. In modern practice, however, a homevisit is quite exceptional and is paid only to the severely disabled orseriously ill when other recourses are ruled out. All patients are normallyrequired to go to the doctor.
It has also become unusual for a personal doctor to be available duringweekends or holidays. His place may be taken by one of his partners in agroup practice, a provision that is reasonably satisfactory. Generalpractitioners, however, may now use one of several commercial deputizingservices that employs young doctors to he on call. Although some of theseyoung doctors may he well experienced, patients do not generally appreciatethis kind of arrangement.
United Stales. Whereas in Britain the doctor of first contact is regularlya general practitioner, in the United States the nature of first-contactcare is less consistent. General practice in the United States has been ina slate of decline in the second half of the 20th century especially inmetropolitan areas. The general practitioner, however, is being replaced tosome degree by the growing field of family practice. In 1969 familypractice was recognized as a medical specialty after the American Academyof 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 largermedical specialties in the United States. The family physicians were thefirst 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. Mostphysicians in the country have traditionally been in some form of privatepractice, whether seeing patients in their own offices. clinics, medicalcentres, or another type of facility and regardless of the patients 'income. Doctors are usually compensated by such state and federallysupported agencies as Medicaid (for treating the poor) and Medicare (fortreating the elderly); not all doctors, however, accept poor patients.
There are also some state-supported clinics and hospitals where the poorand elderly may receive free or low-cost treatment, and some doctors devotea small percentage of their time to treatment of the indigent. Veterans mayreceive free treatment at Veterans Administration hospitals, and thefederal government through its Indian Health Service provides medicalservices to American Indians and Alaskan natives, sometimes using trainedauxiliaries for first-contact care.
In the rural United States first-contact care is likely to come from ageneralist 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'shealth needs until adulthood. Adults frequently make their initial contactwith an internist, whose field is mainly that of medical (as opposed tosurgical) illnesses; the internist often becomes the family physician.
Other adults choose to go directly to physicians with narrower specialties,including dermatologists, allergists, gynecologists, orthopedists, andophthalmologists.
Patients in the United States may also choose to be treated by doctors ofosteopathy. These doctors are fully qualified, but they make up only asmall percentage of the country's physicians. They may also branch off intospecialties, hut general practice is much more common in their group thanamong MD's.
It used to be more common in the United States for physicians providingprimary care to work independently, providing their own equipment andpaying their own ancillary staff. In smaller cities they mostly had fullhospital privileges, but in larger cities these privileges were more likelyto be restricted. Physicians, often sharing the same specialties, areincreasingly entering into group associations, where the expenses of officespace, staff, and equipment may be shared; such associations may work outof suites of offices, clinics, or medical centres. The increasingcompetition and risks of private practice have caused many physicians tojoin Health Maintenance Organizations (HMOs), which provide comprehensivemedical. care and hospital care on a prepaid basis. Thе cost savings topatient's are considerable, but they must use only the HMO doctors andfacilities. HMOs stress preventive medicine and out-patient treatment asopposed to hospitalization as a means of reducing costs, a policy that hascaused an increased number of empty hospital beds in the United States.
While the number of doctors per 100,000 population in the United States hasbeen steadily increasing, there has been a trend among physicians towardthe use of trained medical personnel to handle some of the basic servicesnormally performed by the doctor. So-called physician extender services arecommonly divided into nurse practitioners and physician's assistants, bothof whom provide similar ancillary services for the general practitioner orspecialist. Such personnel do not replace the doctor. Almost all Americanphysicians have systems for taking each other's calls when they becomeunavailable. House calls in the United Stales, as in Britain, have becomeexceedingly rare.
Russia. In Russia general practitioners are prevalent in the thinlypopulated rural areas. Pediatricians deal with children up to about age 15.
Internists look after the medical ills of adults, and occupationalphysicians deal with the workers, sharing care with internists.
Teams of physicians with experience in varying specialties work frompolyclinics or outpatient units, where many types of diseases are treated.
Small towns usually have one polyclinic to serve all purposes. Large citiescommonly have separate polyclinics for children and adults, as well asclinics with specializations such as women's health care, mental illnesses,and sexually transmitted diseases. Polyclinics usually have X-ray apparatusand facilities for examination of tissue specimens, facilities associatedwith the departments of the district hospital. Beginning in the late 1970swas a trend toward the development of more large, multipurpose treatmentcentres, first-aid hospitals, and specialized medicine and health carecentres.
Home visits have traditionally been common, and much of the physician'stime is spent in performing routine checkups for preventive purposes. Somepatients in sparsely populated rural areas may be seen first by feldshers
(auxiliary health workers), nurses, or midwives who work under thesupervision of a polyclinic or hospital physician. The feldsher was once alower-grade physician in the army or peasant communities, but feldshers arenow regarded as paramedical workers.
Japan. In Japan, with less rigid legal restriction of the sale ofpharmaceuticals than in the West, there was formerly a strong tradition ofself-medication and self-treatment. This was modified in 1961 by theinstitution of health insurance programs that covered a large proportion ofthe population; there was then a great increase in visits to the outpatientclinics 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. Asa result of German influence and of their own traditions, Japanesephysicians tended to prefer professorial status and scholarly researchopportunities at the universities or positions in the national orprefectural hospitals to private practice. There were some pioneeringphysicians, 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 andnonprofit 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 passageof the national health insurance acts of 1961 had, as one effect, a severereduction in the amount of time available for any one patient. Perhaps inreaction to this situation, there has been a modest resurgence in thepopularity of traditional Chinese medicine, with its leisurely interview,its dependence on herbal and other "natural" medicines, and its othertraditional diagnostic and therapeutic practices. The rapid aging of the
Japanese population as a result of the sharply decreasing death rate andbirth rate has created an urgent need for expanded health care services/orthe elderly. There has also been an increasing need for centres to treathealth problems resulting from environmental causes.
Other developed countries. On the continent of Europe there are greatdifferences both within single countries and between countries in the kindsof first-contact medical care. General practice, while declining in Europeas elsewhere, is still rather common even in some large cities, as well asin remote country areas.
In The Netherlands, departments of general practice are administered bygeneral practitioners in all the medical schools-an exceptional state ofaffairs-and general practice flourishes. In the larger cities of Denmark,general practice on an individual basis is usual and popular, because thephysician works only during office hours. In addition, there is a dutydoctor service for nights and weekends. In the cities of Sweden, primarycare is given by specialists. In the remote regions of northern Sweden,district doctors act as general practitioners to patients spread over hugeareas; the district doctors delegate much of their home visiting to nurses.
In France there are still general practitioners, but their number isdeclining. Many medical practitioners advertise themselves directly to thepublic as specialists in internal medicine, ophthalmologists,gynecologists, and other kinds of specialists. Even when patients have ageneral practitioner, they may still go directly to a specialist. Attemptsto stem the decline in general practice are being made hy the developmentof group practice and of small rural hospitals equipped to deal with lessserious illnesses, where general practitioners can look after theirpatients.
Although Israel has a high ratio of physicians to population, there is ashortage of general practitioners, and only in rural areas is generalpractice common. In the towns many people go directly to pediatricians,gynecologists, and other specialists, but there has been a reaction againstthis direct access to the specialist. More general practitioners have beentrained, and the Israel Medical Association has recommended that no patientshould be referred to a specialist except by the family physician or oninstructions given by the family nurse. At Tel Aviv University there is adepartment of family medicine. In some newly developing areas, where thedoctor shortage is greatest, there are medical centres at which allpatients are initially interviewed by a nurse. The nurse may deal with manyminor ailments, thus freeing the physician to treat the more seriously ill.
Nearly half the medical doctors in Australia are general practitioners-afar higher proportion than in most other advanced countries-though, aselsewhere, their numbers are declining. They tend to do far more for theirpatients than in Britain, many performing such operations as removal of theappendix, gallbladder, or uterus, operations that elsewhere would becarried out by a specialist surgeon. Group practices are common.

MEDICAL PRACTICE IN DEVELOPING COUNTRIES
China. Health services in China since the Cultural Revolution have beencharacterized by decentralization and dependence on personnel chosenlocally and trained for short periods. Emphasis is given to selflessmotivation, self-reliance, and to the involvement of everyone in thecommunity. Campaigns stressing the importance of preventive measures andtheir implementation have served to create new social attitudes as well asto break down divisions between different categories of health workers.
Health care is regarded as a local matter that should not require theintervention of any higher authority; it is based upon a highly organizedand well-disciplined system that is egalitarian rather than hierarchical,as in Western societies, and which is well suited to the rural areas whereabout two-thirds of the population live. In the large and crowded cities animportant constituent of the health-care system is the residents 'committees, each for a population of 1,000 to 5,000 people. Care isprovided by part-time personnel with periodic visits by a doctor. A numberof residents 'committees are grouped together into neighbourhoods of some
50,000 people where there are clinics and general hospitals staffed bydoctors 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 preventivemedicine centres. In many rural districts people's communes have organizedcooperative medical services that provide primary care for a small annualfee.
Throughout China the value of traditional medicine is stressed, especiallyin the rural areas. All medical schools are encouraged to teach traditionalmedicine as part of their curriculum, and efforts are made to link collegesof Chinese medicine with Western-type medical schools. Medical education isof shorter duration than it is in Europe, and there is greater emphasis onpractical work. Students spend part of their time away from the medicalschool working in factories or in communes; they are encouraged to questionwhat they are taught and to participate in the educational process at allstages. One well-known form of traditional medicine is acupuncture, whichis used as a therapeutic and pain-relieving technique; requiring theinsertion 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 thehealth-care system greatly depends, includes both full-time and part-timeworkers. The latter include so-called barefoot doctors, who work mainly inrural areas, worker doctors in factories, and medical workers inresidential communities. None of these groups is medically qualified. Theyhave had only a three-month period of formal training, part of which isdone in a hospital, fairly evenly divided between theoretical and practicalwork. This is followed by a varying period of on-the-job experience undersupervision.
India. Ayurvedic medicine is an example of a well-organized system oftraditional health care, both preventive and curative, that is widelypracticed in parts of Asia. Ayurvedic medicine has a long tradition behindit, having originated in India perhaps as long as 3.000 years ago. It isstill a favoured form of health care in large parts of the Eastern world,especially in India, where a large percentage of the population use thissystem exclusively or combined with modern medicine. The Indian Medical
Council was set up in 1971 by the Indian government to establishmaintenance of standards for undergraduate and postgraduate education. Itestablishes suitable qualifications in Indian medicine and recognizesvarious forms of traditional practice including Ayurvedic. Unani. and
Siddha. Projects have been undertaken to integrate the indigenous Indianand Western forms of medicine. Most Ayurvedic practitioners work in ruralareas, providing health care to at least 500,000.000 people in India alone.
They therefore represent a major force for primary health care, and theirtraining and deployment are important to the government of India.
Like scientific medicine, Ayurvedic medicine has both preventive andcurative aspects. The preventive component emphasizes the need for a strictcode of personal and social hygiene, the details of which depend uponindividual, climatic, and environmental needs. Rodilv exercises, the use ofherbal preparations, and Yoga form a part of the remedial measures. Thecurative aspects of Avurvcdic medicine involves the use of herbalmedicines, 'external preparations, physiotherapy, and diet. It is aprinciple of Ayurvedic medicini. that the preventive and therapeuticmeasures 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 toall the citizens of the world a level of health that will allow them tolead socially and economically productive lives by the year 2000. By thelate 1980s, however, vast disparities in health care still existed betweenthe rich and poor countries of the world. In developing countries such as
Ethiopia, Guinea, Mali, and Mozambique, for instance, governments in thelate 1980s spent less than $ 5 per person per year on public health, whilein most western European countries several hundred dollars per year wasspent on each person. The disproportion of the number of physiciansavailable between developing and developed countries is similarly wide.
Along with the shortage of physicians, there is a shortage of everythingelse needed to provide medical care-of equipment, drugs, and suitablebuildings, and of nurses, technicians, and all other grades of staff, whosepresence is taken for granted in the affluent societies. Yet there aregreater percentages of sick in the poor countries than in the richcountries. In the poor countries a high proportion of people are young, andall are liable to many infections, including tuberculosis, syphilis,typhon). and cholera (which, with the possible exception of syphilis, arenow 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 drugsthat have been discovered since the 1920s. There is also much malnutritionand anemia, which can be cured if funding is available. There is aprevalence of disorders remediable by surgery. Preventive medicine canensure clean water supplies, destroy insects that carry infections, teachhygiene, and show how to make the best use of resources.
In most poor countries there are a few people, usually living in thecities, who can afford to pay for medical care and in a free market systemthe physicians lend to go where they can make the best living; thissituation causes the doctor-patient ratio to be much higher in the townsthan in country districts. A physician in Bombay or in Rio de Janeiro, forexample, 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 thecities and in the country, can gel medical attention only if it is paid forby the state, by some supranational body, or by a mission or othercharitable organization. Moreover, the quality of the care they receive isoften poor, and in remote regions it may be lacking altogether. Inpractice, hospitals run by a mission may cooperate closely with stale-runhealth 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 hasto be delegated to auxiliaries or nurses, who have to diagnose the commonconditions, 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 anddeal with the more difficult medical problems. People are treated as far aspossible on an outpatient basis from health centres housed in simplebuildings; few can travel except on foot, and, if they are more than a fewmiles from a health centre, they tend not to go there. Health centres alsomay be used for health education.
Although primary health-care service diners from country to country, thatdeveloped in Tanzania is representative of many that have been devised inlargely rural developing countries. The most important feature of the
Tanzanian rural health service is the rural health centre, which, with itsrelated dispensaries, is intended to provide comprehensive health servicesfor the community. The staff is headed by the assistant medical officer andthe medical assistant. The assistant medical officer has at least louryears of experience, which is then followed by further training for 18months. He is not a doctor but serves to bridge the gap between medicalassistant and physician. The medical assistant has three years of generalmedical education. The work of the rural health centres and dispensaries ismainly of three kinds: diagnosis and treatment, maternal and child health,and environmental health. The main categories of primary health workersalso include medical aids, maternal and child health aids, and healthauxiliaries. Nurses and midwives form another category of worker. In thevillages there are village health posts staffed by village medical helpersworking under supervision from the rural health centre.
In some primitive elements of the societies of developing countries, and ofsome developed countries, there exists the belief that illness comes fromthe displeasure of ancestral gods and evil spirits, from the maligninfluence of evil disposed persons, or from natural phenomena that canneither he forecast nor controlled. To deal with such causes there are manyvarieties of indigenous healers who practice elaborate rituals on behalf ofboth the physically ill and the mentally afflicled. If it is understoodthat such beliefs, and other forms of shamanism, may provide a basis uponwhich health care can be based, then primary health care may he said toexist almost everywhere. It is not only easily available but also readilyacceptable, and often preferred, to more rational methods of diagnosis andtreatment. Although such methods may sometimes be harmful, they may oftenbe effective, especially where the cause is psychosomatic. Other patients,however, may suffer from a disease for which there is a cure in modernmedicine.
In order to improve the coverage of primary health-care services and lospread more widely some of the benefits of Wesiern medicine, attempts havesometimes been made to tun.) a means of cooperation, or even integration,between traditional and modern medicine (see above India). In Aluca, forexample, some such attempts are officially sponsored by ministries ofhealth, state governments, universities, and the like, and they have theapproval of WHO, which often lakes the lead in this activity. In view,however, of the historical relationships between these two systems ofmedicine, their different basic concepts, and the fuel that their methodscannot readily be combined, successful merging has been limited.

ALTERNATIVE OR COMPLEMENTARY MEDICINE
Persons dissatisfied with the methods of modern medicine or with itsresults sometimes seek help from those professing expertise in other, lessconventional, and sometimes controversial, forms of health care. Suchpractitioners are not medically qualified unless they are combining suchtreatments with a regular (allopathic) practice, which includes osteopathy.
In many countries the use of some forms, such as chiropractic, requireslicensing and a degree from an approved college. The treatments afforded inthese various practices are not always subjected to objective assessment,yet they provide services that are alternative, and sometimescomplementary, to conventional practice. This group includes practitionersof homeopathy, naturopathy, acupuncture, hypnotism, and various meditativeand quasi-religious forms. Numerous persons also seek out some form offaith healing to cure their ills, sometimes as a means of last resort.
Religions commonly include some advents of miraculous curing within theirscriptures. The belief in such curative powers has been in part responsiblefor the increasing popularity of the television, or "electronic," preacherin 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 possibleto recognize a number of major medical specialties, including internalmedicine, obstetrics and gynecology, pediatrics, pathology, anesthesiology,ophthalmology, surgery, orthopedic surgery, plastic surgery, psychiatry andneurology, radiology, and urology. Hematology was also an important fieldof study, and microbiology and biochemistry were important medically alliedspecialties. Since World War II, however, there has been an almostexplosive increase of knowledge in the medical sciences as well as enormousadvances in technology as applicable to medicine. These developments haveled to more and more specialization. The knowledge of pathology has beengreatly extended, mainly by the use of the electron microscope; similarlymicrobiology, which includes bacteriology, expanded with the growth of suchother subfields as virology (the study of viruses) and mycology (the studyof yeasts and fungi in medicine). Biochemistry, sometimes called clinicalchemistry or chemical pathology, has contributed to the knowledge ofdisease, especially in the field of genetics where genetic engineering hasbecome a key to curing some of the most difficult diseases. Hematology alsoexpanded after World War II with the development of electron microscopy.
Contributions to medicine have come from such fields as psychology andsociology especially in such areas as mental disorders and mentalhandicaps. Clinical pharmacology has led to the development of moreeffective drugs and to the identification of adverse reactions. Morerecently established medical specialties are those of preventive medicine,physical medicine and rehabilitation, family practice, and nuclearmedicine. In the United States every medical specialist must be certifiedby a board composed of members of the specialty in which certification issought. Some type of peer certification is required in most countries.
Expansion of knowledge both in depth and in range has encouraged thedevelopment of new forms of treatment that require high degrees ofspecialization, such as organ transplantation and exchange transfusion; thefield of anesthesiology has grown increasingly complex as equipment andanesthetics have improved. New technologies have introduced microsurgery,laser beam surgery, and lens implantation (for cataract patients), allrequiring the specialist's skill. Precision in diagnosis has markedlyimproved; advances in radiology, the use of ultrasound, computerized axialtomography (CAT scan), and nuclear magnetic resonance imaging are examplesof the extension of technology requiring expertise in the field ofmedicine.
To provide more efficient service it is not uncommon for a specialistsurgeon and a specialist physician to form a team working together in thefield of, for example, heart disease. An advantage of this arrangement isthat they can attract a highly trained group of nurses, technologists.operating room technicians, and so on, thus greatly improving theefficiency of the service to the patient. Such specialization is expensive,however, and has required an increasingly large proportion of the healthbudget of institutions, a situation that eventually has its financialeffect on the individual citizen. The question therefore arises as to theircost-effectiveness. Governments of developing countries have usually found,for instance, that it is more cost-efficient to provide more people withbasic care.
Teaching. Physicians in developed countries frequently prefer posts inhospitals with medical schools. Newly qualified physicians want to workthere because doing so will aid their future careers, though the actualexperience may be wider and better in a hospital without a medical school.
Senior physicians seek careers in hospitals with medical schools becauseconsultant, specialist, or professorial posts there usually carry a highdegree of prestige. When the posts are salaried, the salaries aresometimes, but not always, higher than in a nonteaching hospital. Usually aconsultant who works in private practice earns more when on the staff of amedical school.
In many medical schools there are clinical professors in each of the majorspecialties-such as surgery, internal medicine, obstetrics and gynecologyand psychiatry-and often of the smaller specialties as well. There are alsoprofessors of pathology, radiology, and radiotherapy. Whether professors ornot, all doctors in teaching hospitals have the two functions of caring forthe sick and educating students. They give lectures and seminars and areaccompanied by students on ward rounds.
Industrial medicine. The Industrial Revolution greatly changed, and as arule worsened, the health hazards caused by industry, while the numbers atrisk vastly increased. In Britain the first small beginnings of efforts toameliorate the lot of the workers in factories and mines began in 1802 withthe passing of the first factory act, the Health and Morals of Apprentices
Act. The factory act of 1838, however, was the first truly effectivemeasure in the industrial field. It forbade night work for children andrestricted their work hours to 12 per day. Children under 13 were requiredto attend School. A factory inspectorate was established, the inspectorsbeing given powers of entry into factories and power of prosecution ofrecalcitrant owners. Thereafter there was a succession of acts withdetailed regulations for safety and health in all industries. Industrialdiseases were made notifiable, and those who developed any prescribedindustrial disease were entitled to benefits.
The situation is similar in other developed countries. Physicians are boundby legal restrictions and must report industrial diseases. The industrialphysician's most important function, however, is to prevent industrialdiseases. Many of the measures to this end have become standard practice,but, especially in industries working with new substances, the physicianshould determine if workers are being damaged and suggest preventivemeasures. The industrial physician may advise management about industrialhygiene and the need for safety devices and protective clothing and maybecome involved in building design. The physician or health worker may alsoinform the worker of occupational health hazards.
Modern factories usually have arrangements for giving first aid in case ofaccidents. Depending upon the size of the plant, the facilities may rangefrom a simple first-aid station to a large suite of lavishly equipped roomsand may include a staff of qualified nurses and physiotherapists and one orperhaps more full-time physicians.
Periodic medical examination. Physicians in industry carry out medicalexaminations, especially on new employees and on those returning to workafter sickness or injury. In addition, those liable to health hazards maybe examined regularly in the hope of detecting evidence of incipientdamage. In some organizations every employee may be offered a regularmedical examination.
The industrial and the personal physician. When a worker also has apersona! physician, there may be doubt. in some cases, as to whichphysician bears the main responsibility for his health. When someone has anaccidentor becomes acutely ill at work, the first aid is given or directed by theindustrial physician. Subsequent treatment may be given either at theclinic at work or by the personal physician. Because of labour-managementdifficulties, workers sometimes tend not to trust the diagnosis of themanagement-hired physician.
Industrial health services. During the epoch of the Soviet Union and the
Soviet bloc. industrial health service generally developed more fully inthose countries than in the capitalist countries. At the larger industrialestablishments in the Soviet Union, polyclinics were created to provideboth occupational and general can for workers and their families.
Occupational physicians were responsible for preventing occupationaldiseases and injuries, health screening, immunization and health education.
In the capitalist countries, on the other hand, no fixed pattern ofindustrial health service has emerged. Legislation impinges upon health invarious ways, including the provision of safety measures, the restrictionof pollution and the enforcement of minimum standards of lightning,ventilation, and space per person. In most of these countries there isfound an infinite variety of schemes financed and run by individual firmsor equally, by huge industries. Labour unions have also done much toenforce health codes within their respective industries. In the developingcountries there has been generally little advance in industrial medicine.
Family health care. In many societies special facilities are provided forthe health care of pregnant women mothers, and their young children. Thehealth care needs of these three groups, are generally recognized to be soclosely related as to require a highly integrated service that includesprenatal care, the birth of the baby. the postnatal period, and the needsof the infant. Such a continuum should be followed by a service attentiveto the needs of young children and then by a school health service. Familyclinics are common in countries that have state-sponsored health services,such as those in the United Kingdom and elsewhere in Europe. Family healthcare in some developed countries, such as the United States, is providedfor low-income groups by state-subsidized facilities, but other groupsdefer to private physicians or privately run clinics.
Prenatal clinics provide a number of elements. There is first, the care ofthe pregnant woman, especially if she is in a vulnerable group likely todevelop some complication during the last few weeks of pregnancy andsubsequent delivery. Many potential hazards, such as diabetes and highblood pressure, can be identified and measures taken to minimize theireffects. In developing countries pregnant women are especially susceptibleto many kinds of disorders, particularly infections such as malaria. Localconditions determine what special precautions should he taken to ensure ahealthy child. Most pregnant women, in their concern to have a healthychild, are receptive to simple health education. The prenatal clinicprovides an excellent opportunity to teach the mother how to look afterherself during pregnancy, what to expect at delivery, and how to care forher baby. If the clinic is attended regularly, the woman's record will heavailable to the staff that will later supervise the delivery of the baby:this is particularly important for someone who has been determined to be atrisk. The same clinical unit should he responsible for prenatal, natal, andpostnatal care as well as for the care of the newborn infants.
Most pregnant women can he safely delivered in simple circumstances withoutan elaborately trained staff or sophisticated technical facilities,provided that these can be called upon in emergencies. In developedcountries it was customary in premodern times for the delivery to takeplace in the woman's home supervised by a qualified midwife or by thefamily doctor. By the mid-20th century women, especially in urban areas,usually preferred to have their babies in a hospital, either in a generalhospital or in a more specialized maternity hospital. In many developingcountries traditional birth attendants supervise the delivery. They arewomen, for the most part without formal training, who have acquired skillby working with others and from their own experience. Normally they belongto the local community where they have the confidence ofthe family, where they are content to live and serve, and where theirservices are of great value. In many developing countries the bettertraining of him attendants has a high priority. In developed Westerncountries 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 ofthe mother. They are usually given by the staff of the same unit that wasresponsible for the delivery. Important considerations are the mailer ofbreast-or artificial feeding and the care of the infant. Today theprospects for survival of babies born prematurely or after a difficult andcomplicated labour, as well as for neonates (recently born babies) withsome physical abnormality, are vastly improved. This is due to technicaladvances, 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 thefamily health-care service is the child welfare clinic, which undertakesthe care of the newbom. The first step is the thorough physical examinationof the child on one or more occasions to determine whether or not it isnormal both physically and, if possible, mentally. Later periodicexaminations serve to decide if the infant is growing satisfactorily.
Arrangements can be made for the child to be protected from major hazardsby, for example, immunization and dietary supplements. Any intercurrentcondition, such as a chest infection or skin disorder, can be detectedearly and treated. Throughout the whole of this period mother and child aretogether, and particular attention is paid to the education of the motherfor the care of the child.
A pan of the health service available to children in the developedcountries is that devoted to child guidance. This provides psychiatricguidance to maladjusted children usually through the cooperative work of achild psychiatrist, educational psychologist, and schoolteacher.
Geriatrics. Since the mid-20th century a change has occurred in thepopulation structure in developed countries. The proportion of elderlypeople has been increasing. Since 1983, however, in most European countriesthe population growth of that group has leveled off, although it isexpected to continue to grow more, rapidly than the rest of the populationin 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 considerableburden on health services. In the United Kingdom about one-third of allhospital beds are occupied by patients over 65; half of these arepsychiatric patients. The physician's time is being spent more and morewith the elderly, and since statistics show that women live longer thanmen, geriatric practice is becoming increasingly concerned with thetreatment of women. Elderly people often have more than one disorder, manyof which are chronic and incurable, and they need more attention fromhealth-care services. In the United States there has been some movementtoward making geriatrics a medical specialty, but it has not generally beenrecognized.
Support services for the elderly provided by private or state-subsidizedsources include domestic help, delivery of meals, day-care centres, elderlyresidential homes or nursing homes, and hospital beds either in generalmedical wards or in specialized geriatric units. The degree ofaccessibility "of these services is uneven from country to country andwithin countries. In the United States, for instance, although there aresome federal programs, each state has its own elderly programs, which varywidely. However, as the elderly become an increasingly larger part of thepopulation their voting rights are providing increased leverage forobtaining more federal and state benefits. The general practitioner orfamily physician working with visiting health and social workers and inconjunction with the patient's family often form a working team for elderlycare.
In the developing world, countries are largely spared such geriatricproblems, but not necessarily for positive reasons. A principal cause, forinstance, is that people do not live so long. Another major reason is thatin 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 healthis mainly concerned with the environmental causes of ill health and intheir prevention. Bad drainage, polluted water and atmosphere, noise andsmells, infected food had housing, and poverty in general are all hisspecial concern. Perhaps the most descriptive title he can he given is thatof community physician. In Britain he has been customarily known as themedical officer of health and. in the United Slates, as the health officer.
The spectacular improvement in the expectation of life in the affluentcountries has been due far more to public health measures than to curativemedicine. These public health measures began operation largely in the 19lhcentury. At the beginning of that century, drainage and water supplysystems were all more or less primitive; nearly all the cities of that timehad poorer water and drainage systems than Rome had possessed 1,800 yearspreviously. Infected water supplies caused outbreaks of typhoid, cholera,and other waterborne infections. By the end of the century, at least in thelarger cities, water supplies were usually safe. Food-home infections werealso drastically reduced by the enforcement of laws concerned with thepreparation, storage, and distribution of food. Insect-borne infections,such as malaria and yellow fever, which were common in tropical andsemitropical climates, were eliminated by the destruction of theresponsible insects. Fundamental to this improvement in health has been thediminution of poverty, for most public health measures are expensive. Thepeoples of the developing countries fall sick and sometimes die frominfections 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 thelocal council and is the adviser in health matters. The larger councilsemploy a number of mostly full-time medical officers; in some rural areas,a general practitioner may be employed part-time as medical officer ofhealth:
The medical officer has various statutory powers conferred by acts of
Parliament, regulations and orders, such as food and drugs acts, milk anddairies regulations, and factories acts. He supervises the work of sanitaryinspectors in the control of health nuisances. The compulsorily notifiableinfectious diseases are reported to him, and he takes appropriate action.
Other concerns of the medical officer include those involved with the workof the district nurse, who carries out nursing duties in the home, and thehealth visitor, who gives advice on health matters, especially to themothers of small babies. He has other duties in connection with infantwelfare clinics, creches, day and residential nurseries, the examination ofschoolchildren, child guidance clinics, foster homes, factories, problemfamilies, and the care of the aged and the handicapped.
United States. Federal, state, county, and city governments all have publichealth futtctions. Under the U.S. Department of Health end Human Servicesis the Public Health Service, headed by an assistant secretary for healthand the surgeon general. State health departments are headed by acommissioner of health, usually a physician, who is often in the governor'scabinet. He usually has a board of health that adopts health regulationsand holds hearings on their alleged violations. A state's public healthcode is the foundation on which all county and city health regulations mustbe based. A city health department may be independent of its surroundingcounty health department, or there may be a combined city-county healthdepartment. The physicians of the local health departments are usuallycalled health officers, though occasionally people with this title are notphysicians. The larger departments may have a public health director, adistrict health director, or a regional health director.
The minimal complement of a local health department is a health officer, apublic health nurse, a sanitation expert, and a clerk who is also aregistrar 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 healthprograms at the national level, maintaining close coordination among thefields of preventive medicine, medical care, and welfare and healthinsurance. The departments of health of the prefectures and of the largestmunicipalities operate health centres. The integrated community healthprograms of the centres encompass maternal and child health, communicable -disease control, health education, family planning, health statistics, foodinspection, and environmental sanitation. Private physicians, th