Case history

In 1966, Mrs. Taylor developed pains in her abdomen. The doctor diagnosed gallstones. Mrs. Taylor spent ten days in the hospital while the surgeons removed her gallbladder. The scar, which was 16 cm long, took a month to heal and Mrs. Taylor needed two months off work.

In 1992, Mrs. Taylor’s daughter Louise developed the same symptoms. Louise spent two days in the hospital, where the surgeons removed her gallbladder using a laparoscope. Louise’s scar was only 3 cm long and she was well enough to return to work after only two weeks.

The general practitioner

Britain has a two-tier system of medical care. A person who is ill goes first to a primary care physician or general practitioner. The general practitioner treats most problems himself, and refers patients with unusual or serious illnesses to specialists for secondary care.

The two-tier system has several advantages. Primary care is a cheap and accessible way of treating minor illnesses. The patient can consult the same doctor for almost all illnesses. Specialists do not waste their time on simple problems. In serious illness the general practitioner helps the patient find the most appropriate specialist.

General practice is the “gateway” to specialist health care. But it is also becoming a specialty in its own right. In Britain 99 percent of the population is registered with a general practitioner. Two-thirds of the population visits a general practitioner every year and 98 percent do so at least once every five years. The general practitioner can therefore offer preventive medicine and health education to almost every one in the community. In the past the general practitioner dealt only with “presenting complaints,” that is, the symptoms and anxieties which patients brought along to the doctor. This is called reactive medicine, where the doctor does nothing until the patient has noticed that something is wrong. Modern general practice involves pro-active medicine, where the doctor makes contact with healthy people and offers medical care to people who have not asked for it.

Case history

Timothy, aged ten, was brought to his general practitioner complaining of severe chest pains. The general practitioner knew the family well. She had cared for Timothy’s father three years ago. The father had had chest pains followed by sudden death from a heart attack. The doctor examined Timothy and found nothing wrong with his heart, but noticed that the boy was unhappy and overweight. Timothy said he was frightened that he too might die of a heart attack. The doctor said that there was nothing physically wrong, and Timothy did not need to see a heart specialist. She asked the boy and his mother to come back for some counselling to talk about the father’s death. A few weeks later Timothy stopped getting chest pains.

The doctor in the Third World

The most important cause of illness and death in the Third World is poverty. One quarter of children in poor countries die before they are five years old. They do not die from exotic “tropical diseases” but from trivial illnesses which become killers in conditions of overcrowding and malnutrition. A malnourished child cannot fight infection. Babies and young children die from diarrhea, influenza, and even the common cold. The death rate from measles in Ecuador is 250 times the rate in the United States.

The health policy of any country is a social and political issue. This is particularly true in poor countries. Resources are often spent on a rich minority. In India, 80 percent of people live in small towns and villages but 80 percent of doctors work in the big cities. More than half of the population has no access to a doctor, and many people do not even have access to a nurse or community health worker. Less than 10 percent of the population has basic amenities like clean running water and proper sewage systems. Yet many Indian cities have sophisticated, modern hospitals where doctors perform kidney transplants and open heart surgery.

Drugs and medicines are “big business” in developing countries. Even in villages where there is no doctor, there is usually a pharmacy. People can often buy drugs over the counter—that is, without a doctor’s prescription. They buy antibiotics, strong painkillers, vitamin pills and “tonics.” The patients usually cannot read, and the instructions are often written in a foreign language anyway. People waste their money on useless drugs when they really need good food, better housing, and clean water.

In the past, governments and charities in richer countries tried to provide better health care for people in poor countries. They sent doctors and nurses and built large, modern health clinics. But often, the local people did not come to the clinic because it seemed foreign. The people did not trust doctors who came from foreign countries or from the big cities in their own country. Doctors who come to poor rural communities often cannot understand the culture and traditions of the people there. Dr Halfdan Mahler, who was director-general of the World Health Organization from 1973 to 1988, realized that the well-meaning gestures of foreign governments and charities were often doing more harm than good. In a famous speech to the World Health Assembly in 1977, he said that health care projects in developing countries must occur from the “grass roots”— that is, the local people must be involved in planning and making the changes to the health care system. Instead of providing foreign doctors and expensive new buildings, charities should spend their money on educating and training the local people.

Since about 1980, a lot of the foreign aid to developing countries has been spent on these grass-roots projects. In many poor, rural communities, local women (who are often illiterate before the training begins) have trained as community health workers. They have learned the basic principles of health and hygiene, and how to use a few simple drugs such as aspirin and penicillin. They have also learned about health education, so that they can pass on their knowledge to the community (see Fig. 10.3). Because they know the traditions and fears of the local people and the diseases which occur in their own community, they can often give better medical care than highly-trained foreign doctors and nurses.

Poor people usually die of preventable diseases. The major killer diseases in the Third World today are the same diseases which killed poor people in developed countries 200 years ago – for example, tuberculosis and cholera. These diseases are now rare in developed countries because of a rise in the general standard of living, basic amenities such as clean water and sewage systems, better public health education and widespread immunization. The individual doctor in the Third World often struggles to provide health care in an unhealthy environment to patients who are weak from malnutrition. Neither drugs nor hospitals will cure the diseases of poverty; they often simply divert scarce resources away from the rural poor and towards the urban rich. Governments in developing countries, and organizations, who want to improve health care for the world’s poor, should spend their money on providing basic amenities, educating local people, training community health workers and immunizing the population.