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, 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 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.

Although medical officers in peacetime have some choice of the kind of work

they will do, they are in a chain of command and are subject to military

discipline. When dealing with patients, however, they are in a special

position; they cannot be ordered by a superior officer to give some

treatment or take other action that they believe is wrong. Medical officers

also do not bear or use arms unless their patients are being attacked.

Naval and air force medicine. Naval medical services are run on lines

similar to those of the army. Junior medical officers are attached to ships

or to shore stations and deal with most cases of sickness in their units.

When at sea. medical officers have an exceptional degree of responsibility

in that they work alone, unless they are on a very large ship. In

peacetime, only the larger ships carry a medical officer; in wartime,

destroyers and other small craft may also carry medical officers. Serious

cases go to either a shore-based hospital or a hospital ship.

Flying has many medical repercussions. Cold, lack of oxygen, and changes of

direction at high speed all have important effects on bodily and mental

functions. Armies and air forces may share the same medical services.

A developing field is aerospace medicine. This involves medical problems

that were not experienced before space-flight, for the main reason that

humans in space are not under the influence of gravity, a condition that

has profound physiological effects.

CLINICAL RESEARCH

The remarkable developments in medicine that have been brought about in the

20th century, especially since World War II, have been based on research

either in the basic sciences related to medicine or in the clinical field.

Advances in the use of radiation, nuclear energy, and space research have

played an important part in this progress. Some laypersons often think of

Страницы: 1, 2, 3, 4, 5, 6, 7