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 maycooperate 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
Specialties in medicine. At the beginning of World War II it was possible to recognize a number of major medical specialties, including internal medicine, obstetrics and gynecology, pediatrics, pathology, anesthesiology, ophthalmology, surgery, orthopedic surgery, plastic surgery, psychiatry and neurology, radiology, and urology. Hematology was also an important field of study, and microbiology and biochemistry were important medically allied specialties. Since World War II, however, there has been an almost explosive increase of knowledge in the medical sciences as well as enormous advances in technology as applicable to medicine. These developments have led to more and more specialization. The knowledge of pathology has been greatly extended, mainly by the use of the electron microscope; similarly microbiology, which includes bacteriology, expanded with the growth of such other subfields as virology (the study of viruses) and mycology (the study of yeasts and fungi in medicine). Biochemistry, sometimes called clinical chemistry or chemical pathology, has contributed to the knowledge of disease, especially in the field of genetics where genetic engineering has become a key to curing some of the most difficult diseases. Hematology also expanded after World War II with the development of electron microscopy. Contributions to medicine have come from such fields as psychology and sociology especially in such areas as mental disorders and mental handicaps. Clinical pharmacology has led to the development of more effective drugs and to the identification of adverse reactions. More recently established medical specialties are those of preventive medicine, physical medicine and rehabilitation, family practice, and nuclear medicine. In the United States every medical specialist must be certified by a board composed of members of the specialty in which certification is sought. Some type of peer certification is required in most countries.
Expansion of knowledge both in depth and in range has encouraged the development of new forms of treatment that require high degrees of specialization, such as organ transplantation and exchange transfusion; the field of anesthesiology has grown increasingly complex as equipment and anesthetics have improved. New technologies have introduced microsurgery, laser beam surgery, and lens implantation (for cataract patients), all requiring the specialist's skill. Precision in diagnosis has markedly improved; advances in radiology, the use of ultrasound, computerized axial tomography (CAT scan), and nuclear magnetic resonance imaging are examples of the extension of technology requiring expertise in the field of medicine.
To provide more efficient service it is not uncommon for a specialist surgeon and a specialist physician to form a team working together in the field of, for example, heart disease. An advantage of this arrangement is that they can attract a highly trained group of nurses, technologists. operating room technicians, and so on, thus greatly improving the efficiency of the service to the patient. Such specialization is expensive, however, and has required an increasingly large proportion of the health budget of institutions, a situation that eventually has its financial effect on the individual citizen. The question therefore arises as to their cost-effectiveness. Governments of developing countries have usually found, for instance, that it is more cost-efficient to provide more people with basic care.
Teaching. Physicians in developed countries frequently prefer posts in hospitals with medical schools. Newly qualified physicians want to work there because doing so will aid their future careers, though the actual experience may be wider and better in a hospital without a medical school. Senior physicians seek careers in hospitals with medical schools because consultant, specialist, or professorial posts there usually carry a high degree of prestige. When the posts are salaried, the salaries are sometimes, but not always, higher than in a nonteaching hospital. Usually a consultant who works in private practice earns more when on the staff of a medical school.
In many medical schools there are clinical professors in each of the major specialties—such as surgery, internal medicine, obstetrics and gynecology and psychiatry—and often of the smaller specialties as well. There are also professors of pathology, radiology, and radiotherapy. Whether professors or not, all doctors in teaching hospitals have the two functions of caring for the sick and educating students. They give lectures and seminars and are accompanied by students on ward rounds.
Industrial medicine. The Industrial Revolution greatly changed, and as a rule worsened, the health hazards caused by industry, while the numbers at risk vastly increased. In Britain the first small beginnings of efforts to ameliorate the lot of the workers in factories and mines began in 1802 with the passing of the first factory act, the Health and Morals of Apprentices Act. The factory act of 1838, however, was the first truly effective measure in the industrial field. It forbade night work for children and restricted their work hours to 12 per day. Children under 13 were required to attend School. A factory inspectorate was established, the inspectors being given powers of entry into factories and power of prosecution of recalcitrant owners. Thereafter there was a succession of acts with detailed regulations for safety and health in all industries. Industrial diseases were made notifiable, and those who developed any prescribed industrial disease were entitled to benefits.
The situation is similar in other developed countries. Physicians are bound by legal restrictions and must report industrial diseases. The industrial physician's most important function, however, is to prevent industrial diseases. Many of the measures to this end have become standard practice, but, especially in industries working with new substances, the physician should determine if workers are being damaged and suggest preventive measures. The industrial physician may advise management about industrial hygiene and the need for safety devices and protective clothing and may become involved in building design. The physician or health worker may also inform the worker of occupational health hazards.
Modern factories usually have arrangements for giving first aid in case of accidents. Depending upon the size of the plant, the facilities may range from a simple first-aid station to a large suite of lavishly equipped rooms and may include a staff of qualified nurses and physiotherapists and one or perhaps more full-time physicians.
Periodic medical examination. Physicians in industry carry out medical examinations, especially on new employees and on those returning to work after sickness or injury. In addition, those liable to health hazards may be examined regularly in the hope of detecting evidence of incipient damage. In some organizations every employee may be offered a regular medical examination.
The industrial and the personal physician. When a worker also has a persona! physician, there may be doubt. in some cases, as to which physician bears the main responsibility for his health. When someone has an accident
or becomes acutely ill at work, the first aid is given or directed by the industrial physician. Subsequent treatment may be given either at the clinic at work or by the personal physician. Because of labour-management difficulties, workers sometimes tend not to trust the diagnosis of the management-hired physician.
Industrial health services. During the epoch of the Soviet Union and the Soviet bloc. industrial health service generally developed more fully in those countries than in the capitalist countries. At the larger industrial establishments in the Soviet Union, polyclinics were created to provide both occupational and general can for workers and their families. Occupational physicians were responsible for preventing occupational diseases and injuries, health screening, immunization and health education.
In the capitalist countries, on the other hand, no fixed pattern of industrial health service has emerged. Legislation impinges upon health in various ways, including the provision of safety measures, the restriction of pollution and the enforcement of minimum standards of lightning, ventilation, and space per person. In most of these countries there is found an infinite variety of schemes financed and run by individual firms or equally, by huge industries. Labour unions have also done much to enforce health codes within their respective industries. In the developing countries there has been generally little advance in industrial medicine.