THE PRACTICE OF MODERN MEDICINE, страница 3

Other developed countries. On the continent of Europe there are great differences both within single countries and between countries in the kinds of first-contact medical care. General practice, while declining in Europe as else­where, is still rather common even in some large cities, as well as in remote country areas.

In The Netherlands, departments of general practice are administered by general practitioners in all the medical schools—an exceptional state of affairs—and general prac­tice flourishes. In the larger cities of Denmark, general practice on an individual basis is usual and popular, be­cause the physician works only during office hours. In addition, there is a duty doctor service for nights and weekends. In the cities of Sweden, primary care is given by specialists. In the remote regions of northern Sweden, district doctors act as general practitioners to patients spread over huge areas; the district doctors delegate much of their home visiting to nurses.

In France there are still general practitioners, but their number is declining. Many medical practitioners advertise themselves directly to the public as specialists in inter­nal medicine, ophthalmologists, gynecologists, and other kinds of specialists. Even when patients have a general practitioner, they may still go directly to a specialist. Attempts to stem the decline in general practice are being made hy the development of group practice and of small rural hospitals equipped to deal with less serious illnesses, where general practitioners can look after their patients.

Although Israel has a high ratio of physicians to pop­ulation, there is a shortage of general practitioners, and only in rural areas is general practice common. In the towns many people go directly to pediatricians, gynecolo­gists, and other specialists, but there has been a reaction against this direct access to the specialist. More general practitioners have been trained, and the Israel Medical Association has recommended that no patient should be referred to a specialist except by the family physician or on instructions given by the family nurse. At Tel Aviv University there is a department of family medicine. In some newly developing areas, where the doctor shortage is greatest, there are medical centres at which all patients are initially interviewed by a nurse. The nurse may deal with many minor ailments, thus freeing the physician to treat the more seriously ill.

Nearly half the medical doctors in Australia are general practitioners—a far higher proportion than in most other advanced countries—though, as elsewhere, their numbers are declining. They tend to do far more for their patients than in Britain, many performing such operations as re­moval of the appendix, gallbladder, or uterus, operations that elsewhere would be carried out by a specialist sur­geon. Group practices are common.

MEDICAL PRACTICE IN DEVELOPING COUNTRIES

China. Health services in China since the Cultural Rev­olution have been characterized by decentralization and dependence on personnel chosen locally and trained for short periods. Emphasis is given to selfless motivation, self-reliance, and to the involvement of everyone in the community. Campaigns stressing the importance of pre­ventive measures and their implementation have served to create new social attitudes as well as to break down divisions between different categories of health workers. Health care is regarded as a local matter that should not require the intervention of any higher authority; it is based upon a highly organized and well-disciplined system that is egalitarian rather than hierarchical, as in Western societies, and which is well suited to the rural areas where about two-thirds of the population live. In the large and crowded cities an important constituent of the health-care system is the residents' committees, each for a population of 1,000 to 5,000 people. Care is provided by part-time personnel with periodic visits by a doctor. A number of residents' committees are grouped together into neighbourhoods of some 50,000 people where there are clinics and general hospitals staffed by doctors as well as health auxiliaries trained in both traditional and Westernized medicine. Specialized care is provided at the district level (over 100,000 people), in district hospitals and in epidemic and preventive medicine centres. In many rural districts people's communes have organized cooperative medical services that provide primary care for a small annual fee.

Throughout China the value of traditional medicine is stressed, especially in the rural areas. All medical schools are encouraged to teach traditional medicine as part of their curriculum, and efforts are made to link colleges of Chinese medicine with Western-type medical schools. Medical education is of shorter duration than it is in Europe, and there is greater emphasis on practical work. Students spend part of their time away from the med­ical school working in factories or in communes; they are encouraged to question what they are taught and to participate in the educational process at all stages. One well-known form of traditional medicine is acupuncture, which is used as a therapeutic and pain-relieving tech­nique; requiring the insertion of brass-handled needles at various points on the body, acupuncture has become quite prominent as a form of anesthesia.

The vast number of nonmedically qualified health staff, upon whom the health-care system greatly depends, in­cludes both full-time and part-time workers. The latter include so-called barefoot doctors, who work mainly in rural areas, worker doctors in factories, and medical workers in residential communities. None of these groups is medically qualified. They have had only a three-month period of formal training, part of which is done in a hospi­tal, fairly evenly divided between theoretical and practical work. This is followed by a varying period of on-the-job experience under supervision.

India. Ayurvedic medicine is an example of a well-organized system of traditional health care, both preven­tive and curative, that is widely practiced in parts of Asia. Ayurvedic medicine has a long tradition behind it, having originated in India perhaps as long as 3.000 years ago. It is still a favoured form of health care in large parts of the Eastern world, especially in India, where a large percentage of the population use this system exclusively or combined with modern medicine. The Indian Medical Council was set up in 1971 by the Indian government to establish maintenance of standards for undergraduate and postgraduate education. It establishes suitable qualifi­cations in Indian medicine and recognizes various forms of traditional practice including Ayurvedic. Unani. and Siddha. Projects have been undertaken to integrate the indigenous Indian and Western forms of medicine. Most Ayurvedic practitioners work in rural areas, providing health care to at least 500,000.000 people in India alone. They therefore represent a major force for primary health care, and their training and deployment are important to the government of India.

Like scientific medicine, Ayurvedic medicine has both preventive and curative aspects. The preventive compo­nent emphasizes the need for a strict code of personal and social hygiene, the details of which depend upon individ­ual, climatic, and environmental needs. Rodilv exercises, the use of herbal preparations, and Yoga form a part of the remedial measures. The curative aspects of Avurvcdic medicine involves the use of herbal medicines, 'external preparations, physiotherapy, and diet. It is a principle of Ayurvedic medicini. that the preventive and therapeutic measures be adapted to the personal requirements of each patient.

Other developing countries. A main goal of the World Health Organization (WHO), as expressed in the Alma-Ata Declaration of 1978, is to provide to all the citizens of the world a level of health that will allow them to lead so­cially and economically productive lives by the year 2000. By the late 1980s, however, vast disparities in health care still existed between the rich and poor countries of the world. In developing countries such as Ethiopia, Guinea, Mali, and Mozambique, for instance, governments in the late 1980s spent less than $5 per person per year on public health, while in most western European countries several hundred dollars per year was spent on each person. The disproportion of the number of physicians available between developing and developed countries is similarly wide.

Along with the shortage of physicians, there is a short­age of everything else needed to provide medical care—of equipment, drugs, and suitable buildings, and of nurses, technicians, and all other grades of staff, whose presence is taken for granted in the affluent societies. Yet there are greater percentages of sick in the poor countries than in the rich countries. In the poor countries a high pro­portion of people are young, and all are liable to many infections, including tuberculosis, syphilis, typhon). and cholera (which, with the possible exception of syphilis, are now rare in the rich countries), and also malaria, yaws. worm infestations, and many other conditions occurring primarily in the warmer climates. Nearly all of these in­fections respond to the antibiotics and other drugs that have been discovered since the 1920s. There is also much malnutrition and anemia, which can be cured if funding is available. There is a prevalence of disorders remediable by surgery. Preventive medicine can ensure clean water supplies, destroy insects that carry infections, teach hy­giene, and show how to make the best use of resources.

In most poor countries there are a few people, usually living in the cities, who can afford to pay for medical care and in a free market system the physicians lend to go where they can make the best living; this situation causes the doctor-patient ratio to be much higher in the towns than in country districts. A physician in Bombay or in Rio de Janeiro, for example, may have equipment as lavish as that of a physician in the United States and can earn an excellent income. The poor, however, both in the cities and in the country, can gel medical attention only if it is paid for by the state, by some supranational body, or by a mission or other charitable organization. Moreover, the quality of the care they receive is often poor, and in remote regions it may be lacking altogether. In practice, hospitals run by a mission may cooperate closely with stale-run health centres.

Because physicians are scarce, their skills must be used to best advantage, and much of the work normally done by physicians in the rich countries has to be delegated to auxiliaries or nurses, who have to diagnose the common conditions, give treatment, take blood samples, help with operations, supply simple posters containing health ad­vice, and carry out other tasks. In such places the doctor has lime only to perform major operations and deal with the more difficult medical problems. People are treated as far as possible on an outpatient basis from health centres housed in simple buildings; few can travel except on foot, and, if they are more than a few miles from a health centre, they tend not to go there. Health centres also may be used for health education.

Although primary health-care service diners from coun­try to country, that developed in Tanzania is represen­tative of many that have been devised in largely rural developing countries. The most important feature of the Tanzanian rural health service is the rural health centre, which, with its related dispensaries, is intended to pro­vide comprehensive health services for the community. The staff is headed by the assistant medical officer and the medical assistant. The assistant medical officer has at least lour years of experience, which is then followed by further training for 18 months. He is not a doctor but serves to bridge the gap between medical assistant and physician. The medical assistant has three years of general medical education. The work of the rural health centres and dispensaries is mainly of three kinds: diagnosis and treatment, maternal and child health, and environmental health. The main categories of primary health workers also include medical aids, maternal and child health aids, and health auxiliaries. Nurses and midwives form another category of worker. In the villages there are village health posts staffed by village medical helpers working under supervision from the rural health centre.

In some primitive elements of the societies of developing countries, and of some developed countries, there exists the belief that illness comes from the displeasure of an­cestral gods and evil spirits, from the malign influence of evil disposed persons, or from natural phenomena that can neither he forecast nor controlled. To deal with such causes there are many varieties of indigenous healers who practice elaborate rituals on behalf of both the physically ill and the mentally afflicled. If it is understood that such beliefs, and other forms of shamanism, may provide a basis upon which health care can be based, then primary health care may he said to exist almost everywhere. It is not only easily available but also readily acceptable, and often preferred, to more rational methods of diagnosis and treatment. Although such methods may sometimes be harmful, they may often be effective, especially where the cause is psychosomatic. Other patients, however, may suffer from a disease for which there is a cure in mod­ern medicine.

In order to improve the coverage of primary health-care services and lo spread more widely some of the benefits of Wesiern medicine, attempts have sometimes been made to tun.) a means of cooperation, or even integration, be­tween traditional and modern medicine (see above India). In Aluca, for example, some such attempts are officially sponsored by ministries of health, state governments, universities, and the like, and they have the approval of WHO, which often lakes the lead in this activity. In view, however, of the historical relationships between these two systems of medicine, their different basic concepts, and the fuel that their methods cannot readily be combined, successful merging has been limited.

ALTERNATIVE OR COMPLEMENTARY MEDICINE

Persons dissatisfied with the methods of modern medicine or with its results sometimes seek help from those profess­ing expertise in other, less conventional, and sometimes controversial, forms of health care. Such practitioners are not medically qualified unless they are combining such treatments with a regular (allopathic) practice, which in­cludes osteopathy. In many countries the use of some forms, such as chiropractic, requires licensing and a de­gree from an approved college. The treatments afforded in these various practices are not always subjected to objective assessment, yet they provide services that are al­ternative, and sometimes complementary, to conventional practice. This group includes practitioners of homeopa­thy, naturopathy, acupuncture, hypnotism, and various meditative and quasi-religious forms. Numerous persons also seek out some form of faith healing to cure their ills, sometimes as a means of last resort. Religions commonly include some advents of miraculous curing within their scriptures. The belief in such curative powers has been in part responsible for the increasing popularity of the television, or "electronic," preacher in the United States, a phenomenon that involves millions of viewers. Millions of others annually visit religious shrines, such as the one at Lourdes in France, with the hope of being miracu­lously healed.

SPECIAL PRACTICES AND FIELDS OF MEDICINE