THE PRACTICE OF MODERN MEDICINE, страница 5

Support services for the elderly provided by private or state-subsidized sources include domestic help, delivery of meals, day-care centres, elderly residential homes or nursing homes, and hospital beds either in general medical wards or in specialized geriatric units. The degree of acces­sibility" of these services is uneven from country to country and within countries. In the United States, for instance, although there are some federal programs, each state has its own elderly programs, which vary widely. However, as the elderly become an increasingly larger part of the pop­ulation their voting rights are providing increased leverage for obtaining more federal and state benefits. The gen­eral practitioner or family physician working with visiting health and social workers and in conjunction with the pa­tient's family often form a working team for elderly care.

In the developing world, countries are largely spared such geriatric problems, but not necessarily for positive reasons. A principal cause, for instance, is that people do not live so long. Another major reason is that in the extended family concept, still prevalent among developing countries, most of the caretaking needs of the elderly are provided by the family.

Public health practice. The physician working in the field of public health is mainly concerned with the envi­ronmental causes of ill health and in their prevention. Bad drainage, polluted water and atmosphere, noise and smells, infected food had housing, and poverty in general are all his special concern. Perhaps the most descriptive title he can he given is that of community physician. In Britain he has been customarily known as the medical officer of health and. in the United Slates, as the health officer.

The spectacular improvement in the expectation of life in the affluent countries has been due far more to public health measures than to curative medicine. These public health measures began operation largely in the 19lh cen­tury. At the beginning of that century, drainage and water supply systems were all more or less primitive; nearly all the cities of that time had poorer water and drainage systems than Rome had possessed 1,800 years previ­ously. Infected water supplies caused outbreaks of typhoid, cholera, and other waterborne infections. By the end of the century, at least in the larger cities, water supplies were usually safe. Food-home infections were also drasti­cally reduced by the enforcement of laws concerned with the preparation, storage, and distribution of food. Insect-borne infections, such as malaria and yellow fever, which were common in tropical and semitropical climates, were eliminated by the destruction of the responsible insects. Fundamental to this improvement in health has been the diminution of poverty, for most public health measures are expensive. The peoples of the developing countries fall sick and sometimes die from infections that are virtually unknown in affluent countries.

Britain. Public health services in Britain are organized locally under the National Health Service. The medical officer of health is employed by the local council and is the adviser in health matters. The larger councils employ a number of mostly full-time medical officers; in some rural areas, a general practitioner may be employed part-time as medical officer of health:

The medical officer has various statutory powers con­ferred by acts of Parliament, regulations and orders, such as food and drugs acts, milk and dairies regulations, and factories acts. He supervises the work of sanitary inspec­tors in the control of health nuisances. The compulsorily notifiable infectious diseases are reported to him, and he takes appropriate action. Other concerns of the medical officer include those involved with the work of the district nurse, who carries out nursing duties in the home, and the health visitor, who gives advice on health matters, espe­cially to the mothers of small babies. He has other duties in connection with infant welfare clinics, creches, day and residential nurseries, the examination of schoolchildren, child guidance clinics, foster homes, factories, problem families, and the care of the aged and the handicapped.

United States. Federal, state, county, and city govern­ments all have public health futtctions. Under the U.S. Department of Health end Human Services is the Public Health Service, headed by an assistant secretary for health and the surgeon general. State health departments are headed by a commissioner of health, usually a physician, who is often in the governor's cabinet. He usually has a board of health that adopts health regulations and holds hearings on their alleged violations. A state's public health code is the foundation on which all county and city health regulations must be based. A city health department may be independent of its surrounding county health depart­ment, or there may be a combined city-county health department. The physicians of the local health depart­ments are usually called health officers, though occasion­ally people with this title are not physicians. The larger departments may have a public health director, a district health director, or a regional health director.

The minimal complement of a local health department is a health officer, a public health nurse, a sanitation ex­pert, and a clerk who is also a registrar of vital statistics. There may also be sanitation personnel, nutritionists, so­cial workers, laboratory technicians, and others.

Japan. Japan's Ministry of Health and Welfare directs public health programs at the national level, maintain­ing close coordination among the fields of preventive medicine, medical care, and welfare and health insur­ance. The departments of health of the prefectures and of the largest municipalities operate health centres. The integrated community health programs of the centres en­compass maternal and child health, communicable-disease control, health education, family planning, health statis­tics, food inspection, and environmental sanitation. Pri­vate physicians, through their local medical associations, help to formulate and execute particular public health programs needed by their localities.

Numerous laws are administered through the ministry's bureaus and agencies, which range from public health, en­vironmental sanitation, and medical affairs to the children and families bureau. The various categories of institutions run by the ministry, in addition to the national hospitals, include research centres for cancer and leprosy, homes for the blind, rehabilitation centres, for the physically handicapped, and port quarantine services.

Former Soviet Union. In the aftermath of the dissolu­tion of the Soviet Union, responsibility for public health fell to the governments of the successor countries.

The public health services for the U.S.S.R. as a whole were directed by the Ministry of Health. The ministry, through the 15 union republic ministries of health, di­rected all medical institutions within its competence as well as the public health authorities; and services through­out the country.

The administration was centralized, with little local au­tonomy. Each of the 15 republics had its own ministry of health, which was responsible for carrying out the plans and decisions established by the U.S.S.R. Ministry of Health. Each republic was divided into oblasti, or provinces, which had departments of health directly re­sponsible to the republic ministry of health. Each oblast, in turn, had rayony (municipalities), which have their own health departments accountable to the oblast health de­partment. Finally, each rayon was subdivided into smaller uchastoki (districts).

In most rural rayony the responsibility for public health lay with the chief physician, who was also medical director of the central rayon hospital. This system ensured unity of public health administration and implementation of the principle of planned development. Other health personnel included nurses, feldshers, and midwives.

For more information on the history, organization, and progress of public health, see below.

Military practice. The medical services of armies, navies, and air forces are geared to war. During campaigns the first requirement is the prevention of sickness. In all wars before the 20th century, many more combatants died of disease than of wounds. And even in World War II and wars thereafter, although few died of disease, vast numbers became casualties from disease.

The main means of preventing sickness are the provi­sion of adequate food and pure water, thus eliminating starvation, avitaminosis, and dysentery and other bowel infections, which used to be particular scourges of armies; the provision of proper clothing and other means of pro­tection from the weather; the elimination from the service of those likely to fall sick: the use of vaccination and suppressive drugs to prevent various infections, such as typhoid and malaria; and education in hygiene and in the prevention of sexually transmitted diseases, a particular problem in the services. In addition, the maintenance of high morale has a sinking effect on casualty rates, for, when morale is poor, soldiers are likely to suffer psychi­atric breakdowns, and malingering is more prevalent.

The medical branch may provide advice about disease prevention, but the actual execution of this advice is through the ordinary chains of command. It is the duty of the military, not of the medical, officer to ensure that the troops obey orders not to drink infected water and to take tablets to suppress malaria.

Army medical organisation. The medical doctor of first contact to the soldier in the armies of developed countries is usually an officer in the medical corps. In реагенте the doctor sees the sick and has functions similar to those of the general practitioner, prescribing drugs and dressings and there may be a sick bay where slightly sick soldiers can remain for a few days. The doctor is usually assisted by trained nurses and corpsmen. If a further medical opinion is required, the patient can be referred to a specialist at a military or civilian hospital.

In a war zone, medical officers have an aid post where, with the help of corpsmen, they apply first aid to the walking wounded and to the more seriously wounded who are brought in. The casualties are evacuated as quickly as possible by field ambulances or helicopters. At a com­pany station, medical officers and medical corpsmen may provide further treatment before patients are evacuated to the main dressing station at the field ambulance head­quarters, where a surgeon may perform emergency oper­ations. Thereafter, evacuation may be to casualty clearing stations, to advanced hospitals, or to base hospitals. Air evacuation is widely used.

In peacetime most of the intermediate medical units exist only in skeleton form; the active units are at the battalion and hospital level. When physicians join the medical corps, they may join with specialist qualifications, or they may obtain such qualifications while in the army. A feature of army medicine is promotion to administra­tive positions. The commanding officer of a hospital and the medical officer at headquarters may have no contacts with actual patients.

Although medical officers in peacetime have some choice of the kind of work they will do, they are in a chain of command and are subject to military discipline. When dealing with patients, however, they are in a special po­sition; they cannot be ordered by a superior officer to give some treatment or take other action that they believe is wrong. Medical officers also do not bear or use arms unless their patients are being attacked.

Naval and air force medicine. Naval medical services are run on lines similar to those of the army. Junior medical officers are attached to ships or to shore stations and deal with most cases of sickness in their units. When at sea. medical officers have an exceptional degree of re­sponsibility in that they work alone, unless they are on a very large ship. In peacetime, only the larger ships carry a medical officer; in wartime, destroyers and other small craft may also carry medical officers. Serious cases go to either a shore-based hospital or a hospital ship.

Flying has many medical repercussions. Cold, lack of oxygen, and changes of direction at high speed all have important effects on bodily and mental functions. Armies and air forces may share the same medical services.

A developing field is aerospace medicine. This involves medical problems that were not experienced before space-flight, for the main reason that humans in space are not under the influence of gravity, a condition that has pro­found physiological effects.

CLINICAL RESEARCH

The remarkable developments in medicine that have been brought about in the 20th century, especially since World War II, have been based on research either in the basic sci­ences related to medicine or in the clinical field. Advances in the use of radiation, nuclear energy, and space research have played an important part in this progress. Some laypersons often think of research as taking place only in sophisticated laboratories or highly specialized institutions where work is devoted to scientific advances that may or may not be applicable to medical practice. This notion, however, ignores the clinical research that takes place on a day-to-day basis in hospitals and doctors' offices.

Historical notes. Although the most spectacular changes in the medical scene during the 20lh century, and the most widely heralded, have been the development of potent drugs and elaborate operations, another striking change has been the abandonment of most of the remedies of the past. In the mid-19th century, persons ill with numer­ous maladies were starved (partially or completely), bled, purged, cupped (by applying a tight-fitting vessel filled with steam to some part and then cooling the vessel), and rested, perhaps for months or even years. Much more recently they were prescribed various restricted diets and were routinely kept in bed for weeks after abdominal oper­ations, for many weeks or months when their hearts were thought to be affected, and for many months or years with tuberculosis. The abandonment of these measures may not be though of as involving research, but the physician who first encouraged persons who had peptic ulcers to eat normally (rather than to live on the customary bland foods) and the physician who first got his patients out of bed a week or two after they had had minor coronary thrombosis (rather than insisting on a minimum of six weeks of strict bed rest) were as much doing research as is the physician who first tries out a new drug on a patient. This research, by observing what happens when remedies are abandoned, has been of inestimable value, and the need for it has not passed.