A DOCTOR CONFRONTS V.D.

by Major M. P. Vora, M.B.B.S., D.V.D.

Formerly Senior Specialist in V.D.,

St. George Hospital, Bombay.

Current Medical Practice

A Monthly Journal Devoted to Modern Medicine and Surgery.

Volume No- 20, Number – 7 of July 1976.

Page No. 323 to 326.

It is a well known fact that the incidence of V.D. is rising all over the world and that our country is no exception. The recent revelations from the Institute of Venereology, Madras regarding 20% rise in the incidence in one year (1974 to 1975), the yearly incidence of 0.5 million in that city and 10% students’ involvement could not have come at a more inopportune moment for the country. This disclosure ought to have stunned the public and the health authorities. To curb this galloping epidemic, it is necessary to make the system of diagnosis, treatment and tracing V.D. cases much more effective. This change must begin straight away in the office of the private physician, who treats nearly 80% the V.D. cases and in the public and private hospitals as well.

The experience in the last four decades has convinced the writer that too many private doctors do not do an adequate job of diagnosis, therapy and contact tracing. This is also the case, unfortunately, with most hospitals in the country. This is not at all surprising for most doctors were or are not given necessary education and training or the practical contact with the V.D. problem, during their studies in the medical colleges. Even to this day, venereology does not find a place in education and training in most medical colleges of the country.

Another factor which is responsible for the sorry state is that the handling of V.D. problem has become nobody’s responsibility and that no one is sincerely interested in the problem. The development of antibiotics seems to have lulled the medical profession into a sense of complacency. With the enormous problem, which the country faces today, no doctor could afford to keep silent and inactive. They must play a more active and informed role in the fight against V.D. The public has a major concern in four areas: attitudes, awareness, diagnosis and treatment.

Society’s attitudes pose one of the most difficult obstacles to overcome in achieving the control of V.D. They inhibit the dissemination of correct information concerning V.D., prevent persons who catch the disease from seeking early medical care, and assisting health workers to find and treat their sexual contacts and come in the way of compassionate and effective medical services to V.D. patients. Both the public and the private health workers have the opportunity and obligation to act as agents to change and modify these attitudes. The hostility or total indifference that are too often shown towards V.D. patients, attending public or private clinic, hospital or a private doctors office are intolerable. V.D. patients are often the targets of painful remarks, indifference and indiscrimination. There are some doctors who refuse to see or treat a patient with V.D. because of the stigma it might cast on his patients. Both public and private medicine must recognise that these problems exist and commit resources to solve them. Until we can all regard the patient with V.D. simply as a person with a highly communicable infection, who needs urgent medical help rather than punishment for violation of a moral code, we can never hope to succeed in controlling the V.D. epidemic. Besides, there is an accidental attitude, held by the majority of doctors in private practice, which hampers disease control efforts. It is partly due to indifference and partly due to their concern for the welfare and reputation of their patients. They are unwilling to report V.D. cases they treat, to the public health authorities. Under-reporting of V.D. cases is very common. This has a serious effect on the interviewing of every infectious case, a subject of critical importance, for the success of total effort for the disease control. Their refusal to report V.D. cases is largely dependent on moral grounds and on the presumed right of the individual. But this conception is wrong as it disregards the sum total of rights of individuals, who make the community, demand elimination of V.D. and ask for the protection against risks to health.

Why does a private practitioner consider his few cases to be unimportant to the success of the national control programme and why does he not like to report them for interviewing by the able investigators? It is essential that every new case is reported quickly by every private practitioner, if we are to succeed in our works. The public health on its part must realise that the sanctity of the doctor-patient relationship must be scrupulously maintained and every case reported must be quickly and properly handled. It has to assume the greatest responsibility for handling correctly confidential information supplied to it by the doctor.

The private doctor has a responsibility to strive hard to develop modifications in public attitudes and values, in order to decrease the rate of exposures to infection or to induce them to use rubber sheath properly to protect themselves. His concern should be the victims of disease, including venereal disease. He should be concerned with effects of disease on his community and his country. The private physicians are the most important partners in the public health service of the country. They diagnose and treat the majority of venereal disease cases. Hence they must keep themselves up-to-date through study, meetings, publication and information. They must be convinced of the value of routine screening of the public in general and the high-risk groups and females in the reproductive age in particular, to detect asymptomatic V.D. They must be made aware that they can be of tremendous help in detecting and treating infections in those who are likely to be missed in the ordinary course.

In venereal diseases, diagnosis which is based on solely clinical grounds is less certain and inaccurate in early detection of these infections. All practitioners- public or private – who suspect that they are seeing a case of V.D. are urged to employ appropriate laboratory tests to confirm their clinical impressions. The frequently employed tests are: a dark-field examination and blood serology quantitative for the diagnosis of syphilis; while the smear stained with gram stain, culture on select media, sugar fermentation and oxidase reaction for the diagnosis of gonorrhoea. The temptation to treat V.D. without precise diagnosis should be firmly resisted. Many doctors are even today not aware of the presence of non-specific urethritis (NSU) which may stimulate gonorrhoea and is clinically indistinguishable from it. An accurate diagnosis in the symptomatic patient is necessary for obvious reasons. A careful screening for gonorrhoea and syphilis should be done in all sexually active persons or persons who are frequently exposed to two or more individuals- even though they may be without symptoms. Male homosexuals have a high incidence of syphilis; one has to be extra careful to think of various sexual deviations and exclusion of V.D. in them. In view of high incidence of V.D., all practitioners ought to be particular in excluding V.D. and including them in differential diagnosis by using recommended technics such as careful clinical examination, interrogation and laboratory tests.

So long there is no effective vaccine or a fool-proof prophylactic measure to prevent venereal infection, early and effective treatment of V.D. still, remains the most powerful weapon against the transmission of venereal diseases. The basic tool is treatment to prevent illness and its spread, the chief purpose being eradication of infection and not the relief of symptoms. Hence a doctor must employ the effective treatment regimes appropriate to the disease and give epidemiological treatment to persons recently exposed to either of these two diseases. Aqueous procain penicillin G 4.8 million units i.m. preceded by 2 gm probenicid a half hour prior to the injection is now the treatment of choice for both men and women with a recent exposure (within 24 hours) to an infectious case with either diseases. A patient’s treatment will certainly fail and a ‘ping-pong’ V.D. will ensure, if his or her infected sexual contact or contacts/is or are not treated at the same time. Interviewing the contacts by a special investigator is basic and integral part of an effective therapeutic regime as using appropriate antibiotic in an appropriate dosage. How effective is the procedure is shown by the British example; from a single case of V.D., 1639 cases of V.D. were traced, identified and treated. It can and should never be neglected.

Though the situation demands urgent action, it is a matter of great regret that no progress what-so-ever has been made in increasing and extending our V.D. screening capabilities. An extensive nation-wide programme to provide all doctors with quick, efficient and reliable laboratory services for the diagnosis and “Cure” of V.D. has to be undertaken without least delay. The routine screening for syphilis and gonorrhoea for all patients in the reproductive age-group should be made obligatory in all hospitals and family planning and gynaic clinics. Other appropriate services such as free medicines, confidential interviews of the infected by an experienced field staff, health visitors, V.D. awareness campaign etc. adequately supported by financial grants are necessary adjuncts to the programme of control. A closer liaison between the nation and the states, between the state, private laboratories and practitioners etc should help to stimulate more effective tracing and follow-up of chains of infection. The public health staff must show keen interest and maintain close and constant personal contacts with medical practitioners to secure their co-operation in V.D. control programme. “The use of numbers or codes rather than names to identify V.D. cases must be adopted uniformly for all centres in the country”.

A doctors who reports his case for an interview, should have no ground to fear any breach in confidentiality of his patient. He has to be convinced that the contact-tracing is truly intended to eliminate pockets of disease in his own community and that the procedure will not harm the interest of his patient in any way. This kind of assurance will make him willing to report his cases of V.D. without least hesitation.

The prospects are not bright in other areas and in the implementation of practical and useful recommendations made by various bodies and organisations devoted to V.D. control. There is no evidence as yet that the State or the Central Government will make a long-term and long-range commitment for adequate funds to cope with the V.D. control problems. Sustained efforts continue to be hindered by the lack of national policy, uncertainties over all locations of funds, apathy or rather even hostility at times on the part of those who are administrators of health and medical education. There is also no evidence that V.D. education in medical colleges and in public or private hospitals and health facilities and services have been substantially improved. In fact these seem to steadily deteriorate; nor funds for professional V.D. education or V.D. research are likely to be sanctioned in the near future. Amount of funds sanctioned is in reverse proportion to the extend of spread of V.D.- a noteworthy feature in the country.

Campaigns to make the general public aware of real and present dangers of V.D. have been totally neglected as a rule and no funds are made available for the national V.D. awareness campaign. We need on-going V.D. awareness programmes for a nation-wide distribution and all mass media of communications have to be harnessed into real activity. But there is no indication to the effect. Our Medical Council, the National Board for Post-graduate Education and the I.M.A. have still to recognise venereology as an important speciality, and approve the urgent need for improved V.D. education and training programmes for doctors and students in medical colleges; they are still to call on doctors to participate actively with co-operative efforts for the V.D. control, and to check the rising rate of incidence of V.D. in the country. It would be a great mistake to preserve with the present policy which has been found to be a total failure.

Our attitudes towards venereal diseases and V.D. patient must be altered, if our control efforts are to succeed. The private physician has ample opportunities within his community to offer V.D. information, to make high-risk groups aware of the dangers, to urge them to seek early diagnosis and treatment and co-operate in contact-tracing and finding the source and other contacts and to alter their attitudes. He must keep abreast with new knowledge and technology in venereal diseases. In fact he is the very foundation in the V.D. control programmes. He has the capacity to make or break our national V.D. control programme. Will he or she doctor take up the challenge? The country faces the grave problem for which there is today enough knowledge. He or she must move rapidly from knowledge to action and utilise that knowledge more effectively.