The situation is similar in other developed countries. Physicians are bound by legal restrictions and must report industrial diseases. The industrial physician's most important function, however, is to prevent industrial diseases. Many of the measures to this end have become standard practice, but, especially in industries working with new substances, the physician should determine if workers are being damaged and suggest preventive measures. The industrial physician may advise management about industrial hygiene and the need for safety devices and protective clothing and may become involved in building design. The physician or health worker may also inform the worker of occupational health hazards.
Modern factories usually have arrangements for giving first aid in case of accidents. Depending upon the size of the plant, the facilities may range from a simple first-aid station to a large suite of lavishly equipped rooms and may include a staff of qualified nurses and physiotherapists and one or perhaps more full-time physicians.
Periodic medical examination. Physicians in industry carry out medical examinations, especially on new employees and on those returning to work after sickness or injury. In addition, those liable to health hazards may be examined regularly in the hope of detecting evidence of incipient damage. In some organizations every employee may be offered a regular medical examination.
The industrial and the personal physician. When a worker also has a persona! physician, there may be doubt. in some cases, as to which physician bears the main responsibility for his health. When someone has an accident
or becomes acutely ill at work, the first aid is given or directed by the industrial physician. Subsequent treatment may be given either at the clinic at work or by the personal physician. Because of labour-management difficulties, workers sometimes tend not to trust the diagnosis of the management-hired physician.
Industrial health services. During the epoch of the Soviet Union and the Soviet bloc. industrial health service generally developed more fully in those countries than in the capitalist countries. At the larger industrial establishments in the Soviet Union, polyclinics were created to provide both occupational and general can for workers and their families. Occupational physicians were responsible for preventing occupational diseases and injuries, health screening, immunization and health education.
In the capitalist countries, on the other hand, no fixed pattern of industrial health service has emerged. Legislation impinges upon health in various ways, including the provision of safety measures, the restriction of pollution and the enforcement of minimum standards of lightning, ventilation, and space per person. In most of these countries there is found an infinite variety of schemes financed and run by individual firms or equally, by huge industries. Labour unions have also done much to enforce health codes within their respective industries. In the developing countries there has been generally little advance in industrial medicine.
Family health care. In many societies special facilities are provided for the health care of pregnant women mothers, and their young children. The health care needs of these three groups, are generally recognized to be so closely related as to require a highly integrated service that includes prenatal care, the birth of the baby. the postnatal period, and the needs of the infant. Such a continuum should be followed by a service attentive to the needs of young children and then by a school health service. Family clinics are common in countries that have state-sponsored health services, such as those in the United Kingdom and elsewhere in Europe. Family health care in some developed countries, such as the United States, is provided for low-income groups by state-subsidized facilities, but other groups defer to private physicians or privately run clinics.
Prenatal clinics provide a number of elements. There is first, the care of the pregnant woman, especially if she is in a vulnerable group likely to develop some complication during the last few weeks of pregnancy and subsequent delivery. Many potential hazards, such as diabetes and high blood pressure, can be identified and measures taken to minimize their effects. In developing countries pregnant women are especially susceptible to many kinds of disorders, particularly infections such as malaria. Local conditions determine what special precautions should he taken to ensure a healthy child. Most pregnant women, in their concern to have a healthy child, are receptive to simple health education. The prenatal clinic provides an excellent opportunity to teach the mother how to look after herself during pregnancy, what to expect at delivery, and how to care for her baby. If the clinic is attended regularly, the woman's record will he available to the staff that will later supervise the delivery of the baby: this is particularly important for someone who has been determined to be at risk. The same clinical unit should he responsible for prenatal, natal, and postnatal care as well as for the care of the newborn infants.
Most pregnant women can he safely delivered in simple circumstances without an elaborately trained staff or sophisticated technical facilities, provided that these can be called upon in emergencies. In developed countries it was customary in premodern times for the delivery to take place in the woman's home supervised by a qualified midwife or by the family doctor. By the mid-20th century women, especially in urban areas, usually preferred to have their babies in a hospital, either in a general hospital or in a more specialized maternity hospital. In many developing countries traditional birth attendants supervise the delivery. They are women, for the most part without formal training, who have acquired skill by working with others and from their own experience. Normally they belong to the local community where they have the confidence of
the family,where they are content to live and serve, and where their services are of great value. In many developing countries the better training of him attendants has a high priority. In developed Western countries there has been a trend toward delivery by natural childbirth, including delivery in a hospital without anesthesia, and home delivery.
Postnatal care services are designed to supervise the return to normal of the mother. They are usually given by the staff of the same unit that was responsible for the delivery. Important considerations are the mailer of breast- or artificial feeding and the care of the infant. Today the prospects for survival of babies born prematurely or after a difficult and complicated labour, as well as for neonates (recently born babies) with some physical abnormality, are vastly improved. This is due to technical advances, including those that can determine defects in the prenatal stage, as well as to the growth of neonatology as a specialty. A vital part of the family health-care service is the child welfare clinic, which undertakes the care of the newbom. The first step is the thorough physical examination of the child on one or more occasions to determine whether or not it is normal both physically and, if possible, mentally. Later periodic examinations serve to decide if the infant is growing satisfactorily. Arrangements can be made for the child to be protected from major hazards by, for example, immunization and dietary supplements. Any intercurrent condition, such as a chest infection or skin disorder, can be detected early and treated. Throughout the whole of this period mother and child are together, and particular attention is paid to the education of the mother for the care of the child.
A pan of the health service available to children in the developed countries is that devoted to child guidance. This provides psychiatric guidance to maladjusted children usually through the cooperative work of a child psychiatrist, educational psychologist, and schoolteacher.
Geriatrics. Since the mid-20th century a change has occurred in the population structure in developed countries. The proportion of elderly people has been increasing. Since 1983, however, in most European countries the population growth of that group has leveled off, although it is expected to continue to grow more, rapidly than the rest of the population in most countries through the first third of the 21st century. In the late 20fti century Japan had the fastest growing elderly population.
Geriatrics, the health care of the elderly, is therefore a considerable burden on health services. In the United Kingdom about one-third of all hospital beds are occupied by patients over 65; half of these are 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 increasingly 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 accessibility" 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 population their voting rights are providing increased leverage for obtaining more federal and state benefits. The general practitioner or family physician working with visiting health and social workers and in conjunction with the patient'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 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
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