The practice of modern medicine

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 increas¬ingly 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 acces¬sibility" 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 pop¬ulation their voting rights are providing increased leverage for obtaining more federal and state benefits. The gen¬eral practitioner or family physician working with visiting health and social workers and in conjunction with the pa¬tient'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 envi¬ronmental 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 cen¬tury. 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 previ¬ously. 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 drasti¬cally 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 con¬ferred 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 inspec¬tors 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, espe¬cially 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 govern¬ments 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 depart¬ment, or there may be a combined city-county health department. The physicians of the local health depart¬ments are usually called health officers, though occasion¬ally 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 ex¬pert, and a clerk who is also a registrar of vital statistics. There may also be sanitation personnel, nutritionists, so¬cial workers, laboratory technicians, and others.

Japan. Japan's Ministry of Health and Welfare directs public health programs at the national level, maintain¬ing close coordination among the fields of preventive medicine, medical care, and welfare and health insur¬ance. The departments of health of the prefectures and of the largest municipalities operate health centres. The integrated community health programs of the centres en¬compass maternal and child health, communicable-disease control, health education, family planning, health statis¬tics, food inspection, and environmental sanitation. Pri¬vate 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, en¬vironmental 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 dissolu¬tion 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, di¬rected all medical institutions within its competence as well as the public health authorities; and services through¬out the country.

The administration was centralized, with little local au¬tonomy. 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 re¬sponsible to the republic ministry of health. Each oblast, in turn, had rayony (municipalities), which have their own health departments accountable to the oblast health de¬partment. 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 provi¬sion 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 pro¬tection 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 psychi¬atric