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
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
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
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