Family healthcare. In many societies special facilities are provided for the health care of pregnant women mothers, and their young children. The health care needs of these three groups, are generally recognized to be so closely related as to require a highly integrated service that includes prenatal care, the birth of the baby. the postnatal period, and the needs of the infant. Such a continuum should be followed by a service attentive to the needs of young children and then by a school health service. Family clinics are common in countries that have state-sponsored health services, such as those in the United Kingdom and elsewhere in Europe. Family health care in some developed countries, such as the United States, is provided for low-income groups by state-subsidized facilities, but other groups defer to private physicians or privately run clinics.
Prenatal clinics provide a number of elements. There is first, the care of the pregnant woman, especially if she is in a vulnerable group likely to develop some complication during the last few weeks of pregnancy and subsequent delivery. Many potential hazards, such as diabetes and high blood pressure, can be identified and measures taken to minimize their effects. In developing countries pregnant women are especially susceptible to many kinds of disorders, particularly infections such as malaria. Local conditions determine what special precautions should he taken to ensure a healthy child. Most pregnant women, in their concern to have a healthy child, are receptive to simple health education. The prenatal clinic provides an excellent opportunity to teach the mother how to look after herself during pregnancy, what to expect at delivery, and how to care for her baby. If the clinic is attended regularly, the woman's record will he available to the staff that will later supervise the delivery of the baby: this is particularly important for someone who has been determined to be at risk. The same clinical unit should he responsible for prenatal, natal, and postnatal care as well as for the care of the newborn infants.
Most pregnant women can he safely delivered in simple circumstances without an elaborately trained staff or sophisticated technical facilities, provided that these can be called upon in emergencies. In developed countries it was customary in premodern times for the delivery to take place in the woman's home supervised by a qualified midwife or by the family doctor. By the mid-20th century women, especially in urban areas, usually preferred to have their babies in a hospital, either in a general hospital or in a more specialized maternity hospital. In many developing countries traditional birth attendants supervise the delivery. They are women, for the most part without formal training, who have acquired skill by working with others and from their own experience. Normally they belong to the local community where they have the confidence of
the family,where they are content to live and serve, and where their services are of great value. In many developing countries the better training of him attendants has a high priority. In developed Western countries 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 of the mother. They are usually given by the staff of the same unit that was responsible for the delivery. Important considerations are the mailer of breast- or artificial feeding and the care of the infant. Today the prospects for survival of babies born prematurely or after a difficult and complicated labour, as well as for neonates (recently born babies) with some physical abnormality, are vastly improved. This is due to technical advances, 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 the family health-care service is the child welfare clinic, which undertakes the care of the newbom. The first step is the thorough physical examination of the child on one or more occasions to determine whether or not it is normal both physically and, if possible, mentally. Later periodic examinations serve to decide if the infant is growing satisfactorily. Arrangements can be made for the child to be protected from major hazards by, for example, immunization and dietary supplements. Any intercurrent condition, such as a chest infection or skin disorder, can be detected early and treated. Throughout the whole of this period mother and child are together, and particular attention is paid to the education of the mother for the care of the child.
A pan of the health service available to children in the developed countries is that devoted to child guidance. This provides psychiatric guidance to maladjusted children usually through the cooperative work of a child psychiatrist, educational psychologist, and schoolteacher.
Geriatrics. Since the mid-20th century a change has occurred in the population structure in developed countries. The proportion of elderly people has been increasing. Since 1983, however, in most European countries the population growth of that group has leveled off, although it is expected to continue to grow more, rapidly than the rest of the population in 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 considerable burden on health services. In the United Kingdom about one-third of all hospital beds are occupied by patients over 65; half of these are psychiatric patients. The physician's time is being spent more and more with the elderly, and since statistics show that women live longer than men, geriatric practice is becoming increasingly concerned with the treatment of women. Elderly people often have more than one disorder, many of which are chronic and incurable, and they need more attention from health-care services. In the United States there has been some movement toward making geriatrics a medical specialty, but it has not generally been recognized.
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,andprogress 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.