The practice of modern medicine

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 ad¬vice, 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 coun¬try to country, that developed in Tanzania is represen¬tative 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 pro¬vide 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 an¬cestral 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 mod¬ern 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, be¬tween 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 profess¬ing 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 in¬cludes osteopathy. In many countries the use of some forms, such as chiropractic, requires licensing and a de¬gree from an approved college. The treatments afforded in these various practices are not always subjected to objective assessment, yet they provide services that are al¬ternative, and sometimes complementary, to conventional practice. This group includes practitioners of homeopa¬thy, 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 miracu¬lously 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 medi¬cal specialties, including internal medicine, obstetrics and gynecology, pediatrics, pathology, anesthesiology, ophthal¬mology, surgery, orthopedic surgery, plastic surgery, psy¬chiatry 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 applica¬ble 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 bacte¬riology, 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 con¬tributed 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 espe¬cially in such areas as mental disorders and mental hand¬icaps. 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 re¬habilitation, 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 treat¬ment 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 technolo¬gies 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 im¬proving 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 insti¬tutions, 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 pro¬fessors 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 accom¬panied by students on ward rounds.

Industrial medicine. The Industrial Revolution greatly