HEALTH CARE REVOLUTION
Background
It was recognized that in both developed and developing countries, the standard of health services the public expected was not being provided (38). The services do not cover the whole population. There is lack of services in some areas and unnecessary duplication in others. A very high proportion of the population in many developing countries, and especially in rural areas does not have ready access to health services. The health services favoured only the privileged few and urban dwellers. Although there was the recognition that health is a fundamental human right, there is a denial of this right to millions of people who are caught in the vicious circle of poverty and illhealth. There are marked differences in health status between people in different countries as well as between different groups in the same country; the cost of health care is rising without much improvement in their quality. In short, there has been a growing dissatisfaction with the existing health services and a clear demand for better health care.
MODERN MEDICINE
The dichotomy of medicine into two major branches namely curative medicine, and public health/preventive medicine was evident at the close of the 19th century. After 1900, medicine moved faster towards specialization and a rational, scientific approach to disease. The pattern of disease began to change. With the control of acute infectious diseases, the so-called modern diseases such as cancer, diabetes, cardiovascular disease, mental illness and accidents came into prominence and have become the leading causes of death in industrialized countries. These diseases could not be explained on the basis of the germ theory of disease, nor treated with “magic bullets”. The realization began to dawn that there are other factors or causes in the aetiology of diseases, namely social, economic, genetic, environmental and psychological factors which are equally important. Most of these factors are linked to man’s lifestyle and behavior. The germ theory of disease gave place to a newer concept of disease-“multifactorial causation”. In fact, it was Pettenkofer of Munich (1819-1901) who first mooted the concept of multifactorial causation of disease but his ideas were lost in the bacteriological era. The concept of multifactorial causation was revived by epidemiologists who have contributed significantly to our present day understanding of multifactorial causation of disease and “risk factors” in the aetiology of disease. The developments in modern medicine may be reviewed broadly under the following heads:
1. Curative medicine
Although curative medicine is thousands of years old, modern medicine, as we know today, is hardly 100 years old. Its primary objective is the removal of disease from the patient (rather that from the mass). It employs various modalities to accomplish this objective, e.g., diagnostic techniques, treatment. Over the years, the tolls of diagnosis have become refined, sophisticated and numerous; the armamentarium for treatment more specific and potent. In the middle of the 20th century a profound revolution was brought in “allopathic medicine” which has been defined as “treatment of disease by the use of a drug which produces a reaction that itself neutralizes the disease” (10), by the introduction of antibacterial and antibiotic agents. These discoveries, if they were to be recorded, would fill volumes. Suffice it to say that curative medicine, over the years, has accumulated a vast body of scientific knowledge, technical skills, medicaments and machinery-highly organized-not merely to treat disease but to preserve life itself as far as it could be possible. In reviewing the history of medicine during the past 100 years, one cannot fail to note the tremendous growth of specialization that has taken place in response to advances in medical technology due to changes in the nature and distribution of health and disease pattern in the community, and to the changing emphasis placed by society upon age and sex groups. Some specialties have emerged, based on clearly defined skills such as surgery, radiology, and anaesthesia; some based on parts of the body such as ENT, ophthalmology, cardiology, gynaecology; and, some based on particular age or sex groups such as paediarics, geriatrics and obstetrics. Again, within each speciality, there has been a growth of sub-specialities, as for example, neonatology, perinatology, paediatric cardiology, paediatric neurology and paediatric surgery - all in paediatrics. One wonders whether such microspecialization is needed.
Specialization has no doubt raised the standards of medical care, but it has escalated the cost of medical care and placed specialist medical care beyond the means of an average citizen, without outside aid or charity. It has infringed upon the basic tenets of socialism (i.e., the greatest good of the greatest number) and paved the way to varying degrees of social control over medicine. Specialization has also contributed to the decline of general practice and the isolation of medical practitioners at the periphery of the medical care system (20).
Preventive medicine
Preventive medicine developed as a branch of medicine distinct from public health. By definition, preventive medicine is applied to "healthy" people, customarily by actions affecting large numbers or populations. Its primary objective is prevention of disease and promotion of health.
The early triumphs of preventive medicine were in the field of bacterial vaccines and antisera at the turn of the century which led to the conquest of a wide spectrum of specific diseases. Declines took place in the morbidity and mortality from diphtheria, tetanus, typhoid fever and others. Later, the introduction of tissue culture of viruses led to the development of anti-viral vaccines, e.g., polio vaccines (1955, 1960). The eradication of smallpox (the last case of smallpox occurred in Somalia in 1977) is one of the greatest triumphs of preventive medicine (e.g., against malaria, leprosy, syphilis and other parasitic diseases and even cancer) continues.
Preventive medicine did not confine itself to vaccination and quarantine. Discoveries in the field of nutrition have added a new dimension to preventive medicine. New strategies have been developed for combating specific deficiencies as for example, nutritional blindness and iodine deficiency disorders. The recognition of the role of vitamins, minerals, proteins and other nutrients, and more recently dietary fibre emphasize the nutrition component of preventive medicine.
Another glorious chapter in the history of preventive medicine is the discovery of synthetic insecticides such as DDT, HCH, malathion and other. They have brought about fundamental changes in the strategy in the control of vector-borne diseases (e.g., malaria, leishmaniasis, plague, rickettsial diseases) which have been among the most important world-wide health problems for many years. Despite insecticide resistance and environmental pollution mishaps (e.g., Bhopal tragedy in India in 1984), some of the chemical insecticides such as DDT still remain unchallenged in the control of disease.
The discovery of sulpha drugs, anti-malarials, antibiotics, anti-tubercular and anti-leprosy drugs have all enriched preventive medicine. Chemoprophylaxis and mass drug treatment have become important tools of preventive medicine. The pattern of disease in the community began to change with improved control of infectious diseases through both prevention and treatment, and people are no living for longer years, especially those in developing countries.
A new concept - concept of disease eradication - began to take shape. This concept found ready application in the eradication of smallpox. Eradication of certain other diseases (e.g., measles, tetanus, guineaworm and endemic goitre) are on the anvil.
ln the 1930s, the two most commonly used tests were the serologic blood test for syphilis, and the chest X-ray for tuberculosis. As the number of screening tests increased, the concept of screening for individual diseases entered the multiphasic epoch in early 1950s. In spite of the fact that the utility of screening has been increasingly debated in recent years, screening for disease among apparently healthy people has remained and important part of preventive medicine. An offshoot of the screening is screening for "risk-factors" of disease and identification of "high-risk groups". Since we do not have specific weapons against chronic diseases, screening and regular health checkups have acquired an important place in the early detection of cancer, diabetes, rheumatism & cardiovascular disease, the so-called “diseases of civilization”.
Preventive medicine is currently faced with the problem of "population explosion" in developing countries where population overgrowth is causing social, economic, political and environmental problems. This is another kind of prevention - prevention of a problem that demands a mass attack, if its benefits are to accrue in the present and succeeding generations. Consequently, research in human fertility and contraceptive technology has gained momentum. Genetic counseling is another aspect of the population problem that is receiving attention.
Preventive medicine has become a growing point in medicine (21). Advances in the field of treatment in no way has diminished the need for preventive care nor its· usefulness. Preventive measures are already being applied not only to the chronic, degenerative and hereditary diseases but also to the special problems of old age. In fact, as medical science advances, it will become more and more preventive medical practice in nature. The emergence of preventive paediatrics, geriatrics and preventive cardiology reflect newer trends in the scope of preventive medicine.
Scientific advances, improved living standards and fuller education of the public have opened up a number of new avenues to prevention. Three levels of prevention are now recognized: primary, intended to prevent disease among healthy people; secondary, directed towards those in whom the disease has already developed; and tertiary, to reduce the prevalence of chronic disability consequent to disease. Preventive medicine ranges far beyond the medical field in the narrow sense of the word. Besides communicable diseases, it is concerned with the environmental, social, economic and more general aspects of prevention. Modern preventive medicine has been defined as ''the art and science of health promotion disease prevention, disability limitation and rehabilitation". It implies a more personal encounter between the individual and health professional than public health. In sum, preventive medicine is a kind of anticipatory medicine (22).
Primary health care (39)
With increasing recognition of the failure of existing health services to provide health care, alternative ideas and methods to provide health care have been considered and tried (34,40). Discussing these issues at the Joint WHO UNICEF international conference in 1978 at Altma-Ata (USSR), the governments of 134 countries and many voluntary agencies called for a revolutionary approach to health care. Declaring that "The existing gross inequality in the health status of people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable", the Alma-Ata conference called for acceptance of the WHO goal of Health for All by 2000 A.D. and proclaimed primary health care as way to achieving "Health for All".
Primary health care is a-new approach to health care, which integrates at the community level all the factors required for improving the health status of the population. It consists of at least eight elements (see page 37) described as "essential health care". This presupposes services that are both simple and efficient with regard to cost, techniques, and organization, that are readily accessible to those concerned, and that contribute to improving the living conditions of individuals, families and the community as a whole. Primary health care is available to all people at the first level of health care. It is based on principles of equity, wider coverage, individual and community involvement and intersectoral coordination. Viewed in these terms, primary health care is a radical departure from the conventional health care systems of the past. While it integrates promotive, preventive and curative services, it is also conceived as an integral part of the country's plan for socio-economic development.
The Alma-Ata Declaration called on all governments to formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a national health system. It is left to each country to innovate, according to its own circumstances to provide primary health care. This was followed by the formulation and adoption of the Global strategy for Health for All by the 34th World Health Assembly in 1981. Primary health care got off to a good start in many countries with the theme “Health for All by 2000 A.D.”. It presented a challenge so formidable that its implications boggle the bravest minds. The challenge brought us face-to-face with the Declaration of Alma-Ata.