(WHO), as expressed in the Alma-Ata Declaration of 1978, is to provide to

all the citizens of the world a level of health that will allow them to

lead socially and economically productive lives by the year 2000. By the

late 1980s, however, vast disparities in health care still existed between

the rich and poor countries of the world. In developing countries such as

Ethiopia, Guinea, Mali, and Mozambique, for instance, governments in the

late 1980s spent less than $5 per person per year on public health, while

in most western European countries several hundred dollars per year was

spent on each person. The disproportion of the number of physicians

available between developing and developed countries is similarly wide.

Along with the shortage of physicians, there is a shortage of everything

else needed to provide medical care—of equipment, drugs, and suitable

buildings, and of nurses, technicians, and all other grades of staff, whose

presence is taken for granted in the affluent societies. Yet there are

greater percentages of sick in the poor countries than in the rich

countries. In the poor countries a high proportion of people are young, and

all are liable to many infections, including tuberculosis, syphilis,

typhon). and cholera (which, with the possible exception of syphilis, are

now rare in the rich countries), and also malaria, yaws. worm infestations,

and many other conditions occurring primarily in the warmer climates.

Nearly all of these infections respond to the antibiotics and other drugs

that have been discovered since the 1920s. There is also much malnutrition

and anemia, which can be cured if funding is available. There is a

prevalence of disorders remediable by surgery. Preventive medicine can

ensure clean water supplies, destroy insects that carry infections, teach

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

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 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

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

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