Education
DERMATOLOGY IN DEVELOPING COUNTRIES EUGENE M. FARBER, M.D., AND M. LEXIE NALL, M.S.A.
From the Department of Dermatology, Stanford University School of Medicine, Stanford, California
Marshall' has indicated that dermatology of the tropics is not different from dermatology elsewhere. The basic problems are the same, but the prevalence and distribution of dermatoses differ from place to place under the influence of varying factors: racial, ethnological, climatic and environmental. There are, of course, some dermatoses restricted to the tropics; however, rapid transport has made them cosmopolitan. There are many causal agents in tropical dermatoses: fungi, bacteria, rickettsia and helminths, as well as dermatoses developing because of excessive heat, light and malnutrition.2 Before one considers proposals to lessen the morbidity from tropical skin diseases or to find cures, it is necessary to view the world problems of health.3-6 The relationship between physical environment and tropical skin diseases has been studied more intensely during the last decade than at any early time: Banerjee and Dasai^ in India, Canizares''' ^ and Convit'' in Latin America, and Marshall,'' Presented at tbe International Society of Tropical Dermatology Congress, Sao Paulo, Brazil, September 1-5, 1974. Address for reprints: Eugene M. Farber, M.D., Department of Dermatology, Stanford University School of Medicine, Stanford, CA 94305.
Clarke," and Vollum'' in Africa studied the variation in the prevalence and distribution of these problems in developing countries.^"-'2 y^g vVorld Health Organization functions as the international intelligence agency for communicable diseases upon which all quarantine measures are based; in addition, it sponsors international laboratories for diseases and is the ultimate authority on health standards for food, vaccines, drugs and the lk Health Care Manpower and Economics There is a worldwide shortage of health care professionals and a lack of funds for health care as well. In the world today there is one doctor for every 2,500 people, but in terms of distribution, figures are quite different. For example, in developed countries there is one physician per 1,000 but in less developed countries there is one physician per 5,000 to 8,000. Furthermore, in less developed countries, 80% of the physicians are in urban areas, whereas 80% of the population lives in rural areas.'8. i? |f one made plans to bring health care in less developed countries to the level of developed countries, 3y2 million additional physicians would be required, at a cost of 75,000 million No such possibility exists, for the training of physicians is costly and long.20 Successful now in many areas are training programs for health teams. Paramedical
608
No. 8
DEVELOPING COUNTRIES
personnel are substitutes for the physicians. The cost for training a single physician in the United States is $50,000 to $60,000; the cost of training a medical care auxiliary person is $1,500 to $4,000." Constraints on funds clearly limit provisions for health care and make it impossible to penetrate areas of need.2' Therefore, more efficient ways of using the limited resources of manpower and money must be found. Significant changes are necessary in the present modes of health care and in programs for educating auxiliary medical personnel if progress is to be made.22- 23
Some governments see an immediate need to establish effective medical programs in disease-infested areas so that economic development can take place, but generally national planners have invested much more in aspects of material growth such as roads and dams and military preparedness, and have placed a low priority on health and education. Shortages in health care are greater than often-quoted figures indicate. The facts are that in most of the rural sections of African and Asian countries, the ratios of nurse or physician to population is seldom below one to 5,000, and usually in excess of one to 100,000 and frequently approaches one to 1,000,000. One powerful deterrent in shaping health services is the attitude of physicians toward delegating responsibilities to persons with lesser training. Exclusive of available funds, this is the most serious obstacle to making health care more available in the world today.2'* Rates of population growth are increasing rapidly, with more than half of the world's people living in developing countries. The majority of these people are hungry and undernourished, housed in crowded, unhygienic surroundings and lack even a minimum of health care by World Health Organization standards.20
l^arber and Nail
609
A developing country is fortunate if it has as few as 15,000 patients per physician or can spend more than $1 a year on medical care per capita. In Kenya, for example, the overall physician to patient urban ratio is one to 10,000; and in rural areas the ratio rises as high as one to 50,000.25 Government expenditure on health care services vary greatly.2i' 32 Auxiliary Personnel All nations today have an opportunity to improve health care by training and using auxiliary personnel.2'* Major economies can be realized as functions are transferred from high-salaried to lowersalaried personnel, since the main costs in the health industry are for services rather than goods. In an American Dental Association survey, it was found that each additional full-time auxiliary employee working with a dentist increased the dentist's productivity by approximately 30%. A study by the United States Navy showed that each "middle-level" dental technician could boost the productivity of a dentist well over 50%.2'* Downward delegation of functions are, of course, limited by (1) quality of care expected, (2) acceptability by the patient, and (3) acceptability to the professionals who set standards of medical care. The Peoples Republic of China is an example of a heavily populated country which is working to meet its people's specific health care needs.25. ^o Chu-yuan Cheng^' describes a novel pattern of manpower use and development that has evolved in China during the past 2 decades. The main features are: 1. Development of a variety of health workers through community resources, 2. Equalization of medical manpower distribution.
INTERNATIONAL JOURNAL OF DERMATOLOGY
610
October 1976
Vol. 15
2000
Africa Asia
I960 Europe Latin America Northern America Oceania I
I U.S.S.R.
Fig. 1. World population changes, 1960-2000.
3. A vital health personnel recruitment policy. A; 4. Reorganization of medical education, 5. Instigation of a continuing education program. • In addition to tapping the manpower resources of traditional medicine, an ingenious use has been made of trained lay personnel to perform local health activities (Fig. 2). These include the "barefoot doctor," a subprofessional part-time medical auxiliary, similar to the Russian Feldsher. For equalization of medical manpower distribution, systematic and intensive deployment of mobile medical teams and rotation and resettling of urban physicians to rural communities were
Fig. 2.
methods used in China to solve medical care problems. The Chinese system is effective in China; although not a template for al! developing countries, it is a workable program for China. When not much money is available, there is still an opportunity to render significant help to the sick, if authorities are flexible and use medical auxiliaries. Auxiliary personnel, often working alone, provide the first steps of care. They can evaluate and solve problems; they can also carry out assigned tasks in routine ways. The physician is the member of the health team whose education prepares him to manage health care. Solutions Nations are unequal in the availability of food, clothing, shelter, and not the least in health care services. If the health of mankind is to be of world-wide concern, international cooperation is essential. Wolstenholme'7 suggests a world health service to implement the work of the World Health Organization in pro-
No. 8
DEVELOPING COUNTRIES
viding the essentials of medical therapy, disease prevention and health education throughout the world. All of these plans are dependent on the military and political climates in different countries: they are dependent on economic rivalries as well. The time may come when treatment for a curable disease will be a right enjoyed by every person. The money and manpower picture will always be a critical issue, but use of auxiliaries as primary decision-makers when professionals are not required, while professionals function in positions of leadership, should be implemented by developing countries.22. 23 Since education and research fall under the aegis of universities, universities should be charged with the responsibility of instigating the necessary changes in present concepts of health care delivery and training effective health personnel to understand and handle specific needs of developing countries.is Epidemiological surevillance operations33. 34 allow the World Health Organization to provide technical advice to developing countries in the field of communicable disease control and prevention. The concept of epidemiological surveillance aids development and application of new methods in the study and control of disease.^5, 36 As developing countries exploit their natural resources and join the world market, the amount of financial support for health care should increase. Each country must shape its health services according to its economic situation and traditions.37 Its sole purpose should be to provide anyone who is sick with all of the medical help necessary, for surely there is no one alive who should be deprived of this right. References 1. Marsball, J., Epidemiology of skin diseases. In Essays on Tropical Dermatology. Edited
•
2. 3. 4.
5.
6.
7. 8. 9. 10. 11.
12.
13.
14.
15. 16.
Farber and
Nail
611
by Simons, R. D. G. P., and Marsball, J. Amsterdam, Excerpta Medica Foundation, 1969, pp. 17-23. Kerdel-Vegas, F., Tbe cballenge of tropical dermatology. Trans. St. Jobn's Hosp. Dermatol. Soc. 59:1, 1973. Banerjee, B. N., and Datta, A. K., Prevalence and incidence pattern of skin diseases in Calcutta. Int. J. Dermatol. 12:41, 1973. Canizares, O., Geograpbic dermatology: Mexico and Central America. Tbe influence of geograpbic factors on skin diseases. Arcb. Dermatol. 82:870, 1960. Canizares, O., Epidemiology of tbe dermatoses of Latin America. In Essays on Tropical Dermatology. Edited by Marshall, J.. Amsterdam, Excerpta Medica, 1972, pp. 426431. Convit, J., Investigations of tbe incidence of psoriasis among Latin American Indians. In Proc. 12th Int. Cong. Dermatol. 1962, Washington, D. C, Int. Cong. Series 55. Amsterdam, Excerpta Medica Foundation, 1963, pp. 196-199. Marshall, J., Skin Diseases in Africa. An Essay in Epidemiology. London, Maskew Miller, 1964. Clarke, G. H. V., Skin Diseases in the African. London, H. K. Lewis & Go. Ltd., 1959. Vollum, D. I., An impression of dermatology in Uganda. Trans. St. John's Hosp. Dermatol Soc. 59:120, 1973. Marshall, J., Essays on Tropical Dermatology. Amsterdam, Excerpta Medica, 1972. Tropical Health. A Report on a Study of Needs and Resources. Washington, D. C, National Academy of Sciences—National Researcb Council Publication No. 996, 1962. Prywes, M., Davies, A. M., Health Problems in Developing States. Proceedings of the Fourth Rehovoth Conference 15 to 23 August 1967, Jerusalem and Rehovoth. Nevi' York, Grune & Stratton Inc., 1968. The Work of WHO, 1974. Annual report of the Director-General to the World Health Assembly and to the United Nations. Official records of the WHO No. 221. Geneva, World Health Organization, 1975. Fifth report on the world health situation, 1969-1972. Of-ficial records of the WHO No. 225. Geneva, World Health Organization, 1975. Wilson, J. M. G., and Jungner, G., Principles and practice of screening for disease. Geneva, World Health Organization, 1968. Wolstenholme, G., and O'Connor, M., Health of Mankind. Ciba Foundation 100th Symposium. Boston, Little, Brown & Co., 1967.
612
INTERNATIONAL JOURNAL OF DERMATOLOGY
17. Wolstenholme, G., and O'Connor, M., Teamwork for world health. A Ciba Foundation Symposium in honor of Professor S. Artunkal. London, Churchill, 1971. 18. Bryant, J., Health and the Developing Work. Ithaca, N. Y., Cornell University Press, 1969. 19. Elliott, K., Meeting world health needs: the doctor and the medical auxiliary. World Hospitals 9, July 1963. 20. Kaprio, L. A., Size and distribution of present world resources of doctors, specialists, nurses, midwives, medical tecbnicians, sanitarians and other health staff. In Health of Mankind. Edited by Wolstenholme, G., and O'Connor, M. Boston, Little, Brown & Co., 1967, pp. 218-238. 21. Abel-Smith, J., An international study of health expenditure and its relevance for health planning. Geneva, World Health Organization Public Health Papers No. 32, 1967. 22. Pequignot, H., and Banks, A. L., Education and training facilities, present and potential; and researcb. In Health of Mankind. Edited by Wolstenholm, G., and O'Connor, M. Boston, Little, Brown & Co., 1967, pp. 239-253. 23. Rosenheim, M., Training for research and teaching. In Health Problems in Developing States. Edited by Prywes, M., and Davies, A. M. New York, Crune & Stratton Inc.,
1968, pp. 357-368. 24. Pitcairn, D. M., and Flahault, D., The medical assistant: an intermediate level of health care personnel. Geneva, World Health Organization Public Health Papers 60, 1974. 25. Baker, T. D., Paramedical paradoxes—challenges and opportunities. In Teamwork for World Health. Edited by Wolsteholm, G., and O'Gonnor, M. London, J & A Churchill, 1971, pp. 129-141. 26. Pincus, G., Population growth and age composition. In Health of Mankind. Edited by Wolstenholme, G., and O'Connor, M. Boston, Little, Brown & Co., 1967, pp. 127-148.
October 1976
Vol. 15
27. King, M., Introduction. In Medical Care in Developing Countries. Edited by King, M. Nairobi, Oxford University Press, 1966, pp. 1-19. 28. Snyman, H. W., Factors operative in the economics of health and disease with particular reference to the African region. In Essays on tropical dermatology. Edited by Marshall, J. Amsterdam, Excerpta Medica, 1972, pp. 447-455. 29. Cbeng, C-Y., Health manpower: growth and distribution. In Public Health in Peoples Republic of Cbina. Edited by Wegman, M. E., Lin, T-Y, Purcell, E. F. New York, The Josiah Macy, Jr. Foundation, 1972, pp. 139157. 30. Cheng, T-H., Disease control and prevention. In Public Health in the People's Republic of China. Edited by Wegman, W. E., Lin, T-Y, Purcell, E. F. New York, Josiah Macy, Jr. Foundation, 1973, pp. 185-207. 31. Wen, C, Barefoot doctors in China. Lancet 1:976, 1974. 32. Sidel, V. W., Sidel R., Delivery of medical care in China. Sci. Amer. 230:19, 1974. 33. The training and utilization of feldshers in the USSR. World Health Organization Public Health Papers 56, Geneva, 1974. 34. Greenbaum, G. H., and Beerman, H., Epidemiology of disease of tbe skin. Am. J. Med. Sci. 250:459, 1965. 35. Buck, A. A., Sasaki, T. T., Anderson, R. I., Contrasts in epidemiology. Baltimore, Tbe Johns Hopkins Press, 1968. 36. Hopps, H. C, Cuffey, R. J., Morenoff, J., Richmond, W. L., Sidley, J. D. H., Computerized mapping of disease and environmental data. U. S. Department of Defense, Advanced Research Projects Agency, Washington, DC, 1968. 37. McGlashan, N. D. (ed.). Medical geography: techniques and field studies. London, Methuen & Co. Ltd., 1972.
DERMATOLOGY IN DEVELOPING COUNTRIES EUGENE M. FARBER, M.D., AND M. LEXIE NALL, M.S.A.
From the Department of Dermatology, Stanford University School of Medicine, Stanford, California
Marshall' has indicated that dermatology of the tropics is not different from dermatology elsewhere. The basic problems are the same, but the prevalence and distribution of dermatoses differ from place to place under the influence of varying factors: racial, ethnological, climatic and environmental. There are, of course, some dermatoses restricted to the tropics; however, rapid transport has made them cosmopolitan. There are many causal agents in tropical dermatoses: fungi, bacteria, rickettsia and helminths, as well as dermatoses developing because of excessive heat, light and malnutrition.2 Before one considers proposals to lessen the morbidity from tropical skin diseases or to find cures, it is necessary to view the world problems of health.3-6 The relationship between physical environment and tropical skin diseases has been studied more intensely during the last decade than at any early time: Banerjee and Dasai^ in India, Canizares''' ^ and Convit'' in Latin America, and Marshall,'' Presented at tbe International Society of Tropical Dermatology Congress, Sao Paulo, Brazil, September 1-5, 1974. Address for reprints: Eugene M. Farber, M.D., Department of Dermatology, Stanford University School of Medicine, Stanford, CA 94305.
Clarke," and Vollum'' in Africa studied the variation in the prevalence and distribution of these problems in developing countries.^"-'2 y^g vVorld Health Organization functions as the international intelligence agency for communicable diseases upon which all quarantine measures are based; in addition, it sponsors international laboratories for diseases and is the ultimate authority on health standards for food, vaccines, drugs and the lk Health Care Manpower and Economics There is a worldwide shortage of health care professionals and a lack of funds for health care as well. In the world today there is one doctor for every 2,500 people, but in terms of distribution, figures are quite different. For example, in developed countries there is one physician per 1,000 but in less developed countries there is one physician per 5,000 to 8,000. Furthermore, in less developed countries, 80% of the physicians are in urban areas, whereas 80% of the population lives in rural areas.'8. i? |f one made plans to bring health care in less developed countries to the level of developed countries, 3y2 million additional physicians would be required, at a cost of 75,000 million No such possibility exists, for the training of physicians is costly and long.20 Successful now in many areas are training programs for health teams. Paramedical
608
No. 8
DEVELOPING COUNTRIES
personnel are substitutes for the physicians. The cost for training a single physician in the United States is $50,000 to $60,000; the cost of training a medical care auxiliary person is $1,500 to $4,000." Constraints on funds clearly limit provisions for health care and make it impossible to penetrate areas of need.2' Therefore, more efficient ways of using the limited resources of manpower and money must be found. Significant changes are necessary in the present modes of health care and in programs for educating auxiliary medical personnel if progress is to be made.22- 23
Some governments see an immediate need to establish effective medical programs in disease-infested areas so that economic development can take place, but generally national planners have invested much more in aspects of material growth such as roads and dams and military preparedness, and have placed a low priority on health and education. Shortages in health care are greater than often-quoted figures indicate. The facts are that in most of the rural sections of African and Asian countries, the ratios of nurse or physician to population is seldom below one to 5,000, and usually in excess of one to 100,000 and frequently approaches one to 1,000,000. One powerful deterrent in shaping health services is the attitude of physicians toward delegating responsibilities to persons with lesser training. Exclusive of available funds, this is the most serious obstacle to making health care more available in the world today.2'* Rates of population growth are increasing rapidly, with more than half of the world's people living in developing countries. The majority of these people are hungry and undernourished, housed in crowded, unhygienic surroundings and lack even a minimum of health care by World Health Organization standards.20
l^arber and Nail
609
A developing country is fortunate if it has as few as 15,000 patients per physician or can spend more than $1 a year on medical care per capita. In Kenya, for example, the overall physician to patient urban ratio is one to 10,000; and in rural areas the ratio rises as high as one to 50,000.25 Government expenditure on health care services vary greatly.2i' 32 Auxiliary Personnel All nations today have an opportunity to improve health care by training and using auxiliary personnel.2'* Major economies can be realized as functions are transferred from high-salaried to lowersalaried personnel, since the main costs in the health industry are for services rather than goods. In an American Dental Association survey, it was found that each additional full-time auxiliary employee working with a dentist increased the dentist's productivity by approximately 30%. A study by the United States Navy showed that each "middle-level" dental technician could boost the productivity of a dentist well over 50%.2'* Downward delegation of functions are, of course, limited by (1) quality of care expected, (2) acceptability by the patient, and (3) acceptability to the professionals who set standards of medical care. The Peoples Republic of China is an example of a heavily populated country which is working to meet its people's specific health care needs.25. ^o Chu-yuan Cheng^' describes a novel pattern of manpower use and development that has evolved in China during the past 2 decades. The main features are: 1. Development of a variety of health workers through community resources, 2. Equalization of medical manpower distribution.
INTERNATIONAL JOURNAL OF DERMATOLOGY
610
October 1976
Vol. 15
2000
Africa Asia
I960 Europe Latin America Northern America Oceania I
I U.S.S.R.
Fig. 1. World population changes, 1960-2000.
3. A vital health personnel recruitment policy. A; 4. Reorganization of medical education, 5. Instigation of a continuing education program. • In addition to tapping the manpower resources of traditional medicine, an ingenious use has been made of trained lay personnel to perform local health activities (Fig. 2). These include the "barefoot doctor," a subprofessional part-time medical auxiliary, similar to the Russian Feldsher. For equalization of medical manpower distribution, systematic and intensive deployment of mobile medical teams and rotation and resettling of urban physicians to rural communities were
Fig. 2.
methods used in China to solve medical care problems. The Chinese system is effective in China; although not a template for al! developing countries, it is a workable program for China. When not much money is available, there is still an opportunity to render significant help to the sick, if authorities are flexible and use medical auxiliaries. Auxiliary personnel, often working alone, provide the first steps of care. They can evaluate and solve problems; they can also carry out assigned tasks in routine ways. The physician is the member of the health team whose education prepares him to manage health care. Solutions Nations are unequal in the availability of food, clothing, shelter, and not the least in health care services. If the health of mankind is to be of world-wide concern, international cooperation is essential. Wolstenholme'7 suggests a world health service to implement the work of the World Health Organization in pro-
No. 8
DEVELOPING COUNTRIES
viding the essentials of medical therapy, disease prevention and health education throughout the world. All of these plans are dependent on the military and political climates in different countries: they are dependent on economic rivalries as well. The time may come when treatment for a curable disease will be a right enjoyed by every person. The money and manpower picture will always be a critical issue, but use of auxiliaries as primary decision-makers when professionals are not required, while professionals function in positions of leadership, should be implemented by developing countries.22. 23 Since education and research fall under the aegis of universities, universities should be charged with the responsibility of instigating the necessary changes in present concepts of health care delivery and training effective health personnel to understand and handle specific needs of developing countries.is Epidemiological surevillance operations33. 34 allow the World Health Organization to provide technical advice to developing countries in the field of communicable disease control and prevention. The concept of epidemiological surveillance aids development and application of new methods in the study and control of disease.^5, 36 As developing countries exploit their natural resources and join the world market, the amount of financial support for health care should increase. Each country must shape its health services according to its economic situation and traditions.37 Its sole purpose should be to provide anyone who is sick with all of the medical help necessary, for surely there is no one alive who should be deprived of this right. References 1. Marsball, J., Epidemiology of skin diseases. In Essays on Tropical Dermatology. Edited
•
2. 3. 4.
5.
6.
7. 8. 9. 10. 11.
12.
13.
14.
15. 16.
Farber and
Nail
611
by Simons, R. D. G. P., and Marsball, J. Amsterdam, Excerpta Medica Foundation, 1969, pp. 17-23. Kerdel-Vegas, F., Tbe cballenge of tropical dermatology. Trans. St. Jobn's Hosp. Dermatol. Soc. 59:1, 1973. Banerjee, B. N., and Datta, A. K., Prevalence and incidence pattern of skin diseases in Calcutta. Int. J. Dermatol. 12:41, 1973. Canizares, O., Geograpbic dermatology: Mexico and Central America. Tbe influence of geograpbic factors on skin diseases. Arcb. Dermatol. 82:870, 1960. Canizares, O., Epidemiology of tbe dermatoses of Latin America. In Essays on Tropical Dermatology. Edited by Marshall, J.. Amsterdam, Excerpta Medica, 1972, pp. 426431. Convit, J., Investigations of tbe incidence of psoriasis among Latin American Indians. In Proc. 12th Int. Cong. Dermatol. 1962, Washington, D. C, Int. Cong. Series 55. Amsterdam, Excerpta Medica Foundation, 1963, pp. 196-199. Marshall, J., Skin Diseases in Africa. An Essay in Epidemiology. London, Maskew Miller, 1964. Clarke, G. H. V., Skin Diseases in the African. London, H. K. Lewis & Go. Ltd., 1959. Vollum, D. I., An impression of dermatology in Uganda. Trans. St. John's Hosp. Dermatol Soc. 59:120, 1973. Marshall, J., Essays on Tropical Dermatology. Amsterdam, Excerpta Medica, 1972. Tropical Health. A Report on a Study of Needs and Resources. Washington, D. C, National Academy of Sciences—National Researcb Council Publication No. 996, 1962. Prywes, M., Davies, A. M., Health Problems in Developing States. Proceedings of the Fourth Rehovoth Conference 15 to 23 August 1967, Jerusalem and Rehovoth. Nevi' York, Grune & Stratton Inc., 1968. The Work of WHO, 1974. Annual report of the Director-General to the World Health Assembly and to the United Nations. Official records of the WHO No. 221. Geneva, World Health Organization, 1975. Fifth report on the world health situation, 1969-1972. Of-ficial records of the WHO No. 225. Geneva, World Health Organization, 1975. Wilson, J. M. G., and Jungner, G., Principles and practice of screening for disease. Geneva, World Health Organization, 1968. Wolstenholme, G., and O'Connor, M., Health of Mankind. Ciba Foundation 100th Symposium. Boston, Little, Brown & Co., 1967.
612
INTERNATIONAL JOURNAL OF DERMATOLOGY
17. Wolstenholme, G., and O'Connor, M., Teamwork for world health. A Ciba Foundation Symposium in honor of Professor S. Artunkal. London, Churchill, 1971. 18. Bryant, J., Health and the Developing Work. Ithaca, N. Y., Cornell University Press, 1969. 19. Elliott, K., Meeting world health needs: the doctor and the medical auxiliary. World Hospitals 9, July 1963. 20. Kaprio, L. A., Size and distribution of present world resources of doctors, specialists, nurses, midwives, medical tecbnicians, sanitarians and other health staff. In Health of Mankind. Edited by Wolstenholme, G., and O'Connor, M. Boston, Little, Brown & Co., 1967, pp. 218-238. 21. Abel-Smith, J., An international study of health expenditure and its relevance for health planning. Geneva, World Health Organization Public Health Papers No. 32, 1967. 22. Pequignot, H., and Banks, A. L., Education and training facilities, present and potential; and researcb. In Health of Mankind. Edited by Wolstenholm, G., and O'Connor, M. Boston, Little, Brown & Co., 1967, pp. 239-253. 23. Rosenheim, M., Training for research and teaching. In Health Problems in Developing States. Edited by Prywes, M., and Davies, A. M. New York, Crune & Stratton Inc.,
1968, pp. 357-368. 24. Pitcairn, D. M., and Flahault, D., The medical assistant: an intermediate level of health care personnel. Geneva, World Health Organization Public Health Papers 60, 1974. 25. Baker, T. D., Paramedical paradoxes—challenges and opportunities. In Teamwork for World Health. Edited by Wolsteholm, G., and O'Gonnor, M. London, J & A Churchill, 1971, pp. 129-141. 26. Pincus, G., Population growth and age composition. In Health of Mankind. Edited by Wolstenholme, G., and O'Connor, M. Boston, Little, Brown & Co., 1967, pp. 127-148.
October 1976
Vol. 15
27. King, M., Introduction. In Medical Care in Developing Countries. Edited by King, M. Nairobi, Oxford University Press, 1966, pp. 1-19. 28. Snyman, H. W., Factors operative in the economics of health and disease with particular reference to the African region. In Essays on tropical dermatology. Edited by Marshall, J. Amsterdam, Excerpta Medica, 1972, pp. 447-455. 29. Cbeng, C-Y., Health manpower: growth and distribution. In Public Health in Peoples Republic of Cbina. Edited by Wegman, M. E., Lin, T-Y, Purcell, E. F. New York, The Josiah Macy, Jr. Foundation, 1972, pp. 139157. 30. Cheng, T-H., Disease control and prevention. In Public Health in the People's Republic of China. Edited by Wegman, W. E., Lin, T-Y, Purcell, E. F. New York, Josiah Macy, Jr. Foundation, 1973, pp. 185-207. 31. Wen, C, Barefoot doctors in China. Lancet 1:976, 1974. 32. Sidel, V. W., Sidel R., Delivery of medical care in China. Sci. Amer. 230:19, 1974. 33. The training and utilization of feldshers in the USSR. World Health Organization Public Health Papers 56, Geneva, 1974. 34. Greenbaum, G. H., and Beerman, H., Epidemiology of disease of tbe skin. Am. J. Med. Sci. 250:459, 1965. 35. Buck, A. A., Sasaki, T. T., Anderson, R. I., Contrasts in epidemiology. Baltimore, Tbe Johns Hopkins Press, 1968. 36. Hopps, H. C, Cuffey, R. J., Morenoff, J., Richmond, W. L., Sidley, J. D. H., Computerized mapping of disease and environmental data. U. S. Department of Defense, Advanced Research Projects Agency, Washington, DC, 1968. 37. McGlashan, N. D. (ed.). Medical geography: techniques and field studies. London, Methuen & Co. Ltd., 1972.
