CONTROL OF VENEREAL DISEASES

by Major Dr. M. P. Vora, M.B.B.S.

The Social Service Quarterly

The Organ of the Social Service League

Vol. No. XXXIII, No. 1 of July 1947

Pages No. 1 to 13

The wide dissemination of venereal diseases in classes and communities of all countries of the world and the extensive havoc resulting there from, especially during war- time and post- war period, are not sufficiently understood by the public. Venereal diseases imperil the health, deprive the man of his fitness to work and impair the possibility of a successful marriage and begetting and rearing healthy children. An amount of human wastage and economic loss on account of these diseases is beyond imagination. The exact death rate due to syphilis alone cannot be ascertained as the number of nomenclature for diseases that may clock syphilis on a death certificate is very great. Two of the most tragic aspect of these diseases is the innocent victims who acquire disease from their marital partners and the innocent children who inherit from their parents. The wastage of young life and of the financial resources of the nation is so great that it has made it essential to devise ways and means of prevention and control of venereal diseases. It is not difficult to conceive the social repercussions of this social scourge.

India being the operational base in the recent global war there was a tremendous influx of people belonging to different nationalities as the result of which the incidence of V.D. in this country has gone up by many hundred percent. The incidence though highest in urban areas, is not known in the mofussil. If the infected persons are not attended and timely precautions are not taken now, venereal diseases are bound to spread rapidly in the entire country, thereby causing incalculable loss of national economy and man-power.

The modern concept of the functions of the state and the medical men is not only to treat diseases but to plan methods of their prevention and control. The ultimate aim of the intricate and vast machinery of the department of health is to prevent diseases and to make life more comfortable. However, venereal diseases, one of the groups of the communicable diseases, have been neglected and left out of consideration. “It is intolerable and illogical anachronism that most easily controllable and most wide-spread and most deadly of chronic infectious diseases, should be specially selected for exemption form regulations, prevention and proper treatment”. “How then” asks Sir Malcom Morris, “can we account for this staggering anomaly, that disease which makes far more damaging inroads on the health and efficiency of the nation than some of those which the state has for years been vigorously combating, should have been left to pursue their baleful course unchecked”. The cause of purposeful silence observed and the reason why they have been too much set apart from other communicable diseases will be found in the stigma attached to these diseases. The stigma must be removed, for the net result of this attitude is the complete neglect of the social and economic aspects. Unfair as it is, the attention is focused on the infected person rather than the afflicted community, on the illness of Mr. X rather than disease in the country. The infected men are as much the victims of the war of circumstances, in their own way, as are the wounded and the air-raid casualties. A number of unfortunate cases are mere accidents in the course of their duties, the others are infected trough a single exposure and there are innocent victims like marital partners and children born of infected parents. Persons with recently acquired venereal infections are potentially valuable to the community because they can supply details of the sources of infection and the circumstances in which access was gained to the sources. This fact must not be lost sight of. Venereal diseases like measles, typhoid, tuberculosis, small pox and diphtheria are communicable diseases in their own way. It is; therefore, wrong to look upon them differently. Why then the accepted principles, which govern the control of communicable diseases, are not equally applied to the venereal diseases? There is little doubt that syphilis and gonorrhoea can be easily eliminated from the community if those suffering from them were immediately detected, treated and prevented from sexual congress until rendered completely non-infectious or cured.

The recognition and elimination of the source of infection is of prime importance in the successful control of a communicable disease. And where the greatest progress in the shortest time is desired, the most effective force must be concentrated at this point. The complete knowledge of causes of communicable diseases is essential. The causes are of two kinds: the active infectious agents and predisposing factors. In respect of venereal diseases one is familiar with the infectious agents, gonococcus in gonorrhoea, and Tryponema pallida in syphilis, and specific viruses and bacteria in the less common of the group. The factors which predispose to venereal infections are numerous and the precise information in respect of them is lacking. Roughly speaking they depend on complicated psychological, physiological, social and economic influences. Uncertainty of conditions, absence from home influences, lack of healthy means of distraction, economic stress leading to inadequate supply of housing and late marriages are some of the main contributing factors. It is not difficult to suggest constructive measures even in the absence of accurate and definite knowledge regarding these influences.

Clinical diagnosis- Having known the communicable nature of the disease, the next step is to establish the criteria for its recognition in its natural environments. In contrast to other communicable diseases, the technical methods for recognition of the two important venereal diseases are very simple and readily available. Furthermore their spread is in only way, by direct contact usually sexual. This fact adds greatly to the value of carefully taken history. In the male particularly, the clinical symptoms and physical signs of gonorrhoea and to some extent of syphilis are well defined. Demonstration of causative agents by laboratory help is by no means difficult. From professional point this is not always necessary in every case but is required often for moral implications. Gonorrhoea can be diagnosed on the basis of history, clinical symptoms and physical signs. The United States Army has recognized this principle by prescribing that demonstration of organism, while desirable is not essential for the diagnosis of gonorrhoea; and the diagnosis, other than gonorrhoea, is not permitted in a patient with urethral discharge until gonorrhoea is convincingly excluded. The error on this account is surprisingly negligible.

On the contrary, confirmation of diagnosis of syphilis by laboratory is essential and the methods for this purpose are simple, efficient and reliable. In the presence of typical clinical evidence a diagnosis of syphilis can be made on the basis of the demonstration of motile Tryponema pallida in the serum from the lesion or positive serologic test for syphilis. In the absence of typical clinical evidence, a diagnosis of syphilis must not be made on the basis of serologic test alone for there are various conditions as malaria which are known to give false positive reaction. Further, in the absence of clinical manifestations, a diagnosis of syphilis will not be justified until a positive serologic test has been confirmed and are found to remain persistently positive at intervals of 2 to 4 weeks over a minimum period of three months. The less common venereal diseases, chancroid, lymphogranuloma, venereum and granuloma inguinale are equally well defined clinical entities and adequate criteria for their diagnosis are not lacking.

Detection of foci of infection- Primarily one must recognize the existing foci of infection from which new infection may originate. In many diseases foci of infection are so complicated and widely spread as to be difficult to identify; while in venereal diseases, the host is the whole and sole reservoir. Problem is, therefore, very much simplified and becomes merely a matter of identifying human beings suffering from these diseases. The patients with recent infection are valuable for they can easily furnish necessary details regarding the sources of infections. The individual case-finding is the most productive and in general the most readily accomplished.

In case-finding by contact investigation a number of separate procedures are involved. Firstly, a history of all recent sexual contacts is obtained and diagnosis of venereal disease in the patient is confirmed. This roster of contacts serves to determine all possible links in the continued chain of infection and permits working both backwards and forwards from the established case. Secondly, to visit each contact to tell her or him that he or she may have venereal infection and needs medical examination. Any implication of accusation must be scrupulously avoided. The method of approach should show a keen desire to be helpful and should be entrusted to the professional health visitor genuinely interested in curbing the spread of infections. The aim is to bring the person to proper facilities for examination and treatment, if necessary. The required medical attendance may be secured privately or through a clinic at the patient’s liking. A good contact worker will be a great asset in attending these problems. The final feature of case-finding is to make sure that venereal disease is found, treatment is followed to completion. This is known as ‘case-holding’. Lapses in treatment are common among patients with venereal diseases, and repeated follow up visits are often necessary. The chief achievement of this method of case finding is the removal of a focus of infection from the community. This factor is of the utmost importance among the measures which contribute to the reduction of the incidence of V.D. In addition, the individual concerned is benefited from the recognition and care of his infection. A collection and study of a large number of such reports will naturally form the basis for improved methods of administrative control for the future.

Much will depend on the proper selection of the investigators or contact workers. The choice of a public health nurse is the best for the purpose; female being best suited to female contacts and male to male contacts. Contact investigation is distinctly a public health procedure to be administered by a public health authority. In respect of case-holding or the investigation of defaulters in treatment, the choice of a trained social worker is the best and is to be preferred to that of a public health nurse. The case -finding and the case- holding teams should have their office within and be a part of the clinic where the patients are treated. This is particularly true if case-finding and case-holding are a combined responsibility.

The work of United States Army nurses, assigned to case-finding in the venereal diseases in the U.K., shows the effectiveness of this procedure. Not-with-standing the numerous difficulties that confront a foreigner, their results were very encouraging. 1718 American soldiers suffering from V.D were interviewed. Though contacts were not Americans, and their approach and intimate understanding were difficult, sufficient information was obtained for 782 or about 46% of the sexual contacts involved; while with scanty and incomplete information it was possible to locate 457 or 58% of the actually sought. Further, success and efficiency are obvious from the fact that 223 of the girls were registered in the clinics by the nurse, 109 were referred to the clinics for the treatment, and 17 were registered with private physicians. Thus a total of 349 or 76% were acquainted with the potential dangers and given the advantage of treatment. In addition, 61 contacts were already under observation at clinics, 10 were under care of private practitioners, and 18 were in institutions i.e. a total of 89. Only 19 contacts were found unco-operative i.e. 4%. It is to be noted that in spite of the procedures of the public health department and V.D. consciousness due to broad education that exist in the U.K., less than a sixth i.e. 71, excluding 18 in the institutions, of the relatively large group had sought medical care, and only a fifth were receiving it by any means, and yet the vast majority of the remaining were willing to do so when the need was explained to them. The importance of contact investigation is clearly demonstrated in the above results.

Quarantine of known contacts- This is a time honored procedure in the control of communicable diseases. Having knowledge of the exposure of a person to a disease, his movements can be restricted; and he can be observed for an early evidence of developing infection but this is not generally applicable to venereal diseases. Its application will be voluntary through education in the risks of infection and involves early report to a physician for an examination. Thus known contacts to venereal diseases can be kept so to say in quarantine until freedom from infection is established. This is a practical method of dealing with the infectious prostitutes.

House-to-house canvas- This is the effective way to determine the incidence of a disease. It has no place in the crusade against the venereal diseases, but it can be used in a modified form for the purpose. The serological survey for syphilis is a special application of the principle of house to house canvas. It may be applied to various institutions or individual groups or as a pre-requisite to marriage, or as a routine in prenatal care and in patients admitted to hospitals. It is very heartening that such a practice is becoming popular and is bound to procure good returns. Periodical physical examination is another recognized method of identifying foci of infection and to detect new cases in incipiancy. In addition, these periodical health examinations are increasingly stressed as fundamental to good preventive medical practice. A serologic test for syphilis and inquiry for a history suggesting gonorrhoea should be a part of any examination of this type or any general medical examination. A special plea is to be made for testing blood for syphilis as routine in every enceinte woman and in every candidate before marriage; this is done in most civilized countries- as an effective measures to reduce the incidence of congenital syphilis.

Notification by practitioners to health agencies- This is a recognized part of the control programme of most communicable diseases. There is no reason why the venereal diseases, since they are communicable should not be treated like other diseases. Lack of a system of reporting is largely dependent on moral grounds, on the presumed rights of an individual. But this conception is obviously wrong, as it disregards the sum total of rights of individuals who make up the community, demand elimination of venereal diseases and ask for protection against risks to health. Some form of legal notification is an essential requirement for public health programme of almost all countries. The usual practice is to make a confidential report when the infected or the infectious person refers for advice or refuses treatments. This report is necessary for the protection of others and for accelerating the possibility of eradication of foci of infection. It also permits distribution of effort to deal with the problem according to need.

Distribution of venereal diseases- A tendency towards grouping of cases is a recognized characteristic of a communicable disease. The size of these collections, their rapidity of development, their varying distribution in regard to time, place, individual, capacity to resist infection etc., depend on number of factors. Our ignorance with regards to these points is largely due to our indifferent attitude shown towards these diseases. The importance of adequate case-finding as the first step towards this has been sufficiently stressed. Both the individual and the community are profited as the accumulated experience is periodically subjected to analysis in order to determine the nature, distribution, extent and significance of these diseases. Unless the accepted epidemiological methods are applied, it will not be possible to enforce fully the programme of control i.e. direct scientific attack.

Some communicable diseases are restricted to certain epidemic area, while others of more universal distribution show well marked variation from place to place. The venereal diseases have universal distribution though certain countries are more affected than others. Before the war Sweden was considered to have the lowest incidence of syphilis. Italy and France are supposed to have a fairly high prevalence. However, in the majority of countries the information is indefinite and fragmentary. Industrial areas and cities are more affected than mofussil. The moving population seems to have a greater affinity towards communicable diseases in general and venereal diseases in particular. Accordingly one expects and finds increased frequency of these diseases among refugees, immigrants and soldiers especially during and post-war times. The needs for special measures for the control of venereal diseases for these groups are very evident. Where the mass movements are of soldiers under military control, it is relatively easy to develop and employ methods which effectively prevent either receiving or transmitting. With civilian population this problem is much more difficult on account of various reasons but is not necessarily beyond tackle. Racial differences do not seem to have any marked influence.

It is a common practice to speak of “the venereal diseases” as a group. Nevertheless, a full appreciation of the problem requires frequent examination of population of total incidence and for relative distribution. Industrial and time variations do occur according to sociological and economic changes. Syphilis has had epidemics from time to time but very little is known or appreciated.

Table showing proportion of different venereal diseases in a clinic:

Method of control- Three general principles guide in the attack on a communicable disease. Wherever feasible the most satisfactory method is the destruction or elimination of the reservoirs of infection. The second general method is to break the chain of infection at the point of transfer. Finally, steps to be taken to increase the resistance of the individual. The choice of the method and the proportion of effort to be devoted on each principle will depend on the result of the analysis of epidemiological features of the disease concerned. In the control of venereal diseases the paramount importance of the first two principles is quite obvious.

Attack on the reservoirs of infection- Application of this principle so far as it concerns venereal diseases is very simple. The only reservoir of infection is the man and the method of attack is treatment of existing infection. With improved methods of treatment that are now available a person with either gonorrhoea or syphilis can be promptly rendered non-infectious. The provision of adequate treatment facilities is an integral part of the control programme; and no scheme of control of V.D. will be possible unless the responsibility is adequately shouldered and financed by the state. In a vast country like India, employment of mobile clinics or flying squads, used so successfully in Tsarist Russia would prove of immense value. In the establishment of mobile venereal clinics, the last war saw distinct advance in the medical unit formation and the experience has proved the wisdom of this policy. The present day tendency to incorporate treatment facilities within the clinics of general hospitals is to be praised and has double advantage. It contributes towards bringing these diseases within the full cope of good medical care and at the same time reduces the chance of exposing the sufferer to the public eye. In considering the treatment one must not forget preventive measures. A special plea is to be made for providing, free of charge, facilities for the diagnosis of V.D. Elimination of reservoirs of infection lies in the full scale effort towards the discouragement and repression of prostitution, which is the focus of origin. The necessity of focal attack cannot be over-estimated. Here one is concerned with the discovery of the prostitute and the necessary treatment to eliminate infection and improved social and legal effort to limit her activities and to provide healthy means of distraction. Analysis of the sources of all venereal infections would be interesting from the point of study and may show whether contacts with amateurs or prostitutes are more likely to result in infections.

Interrupting the spread of infection- Of the three methods for the control of a communicable disease, those directed towards interrupting the spread of infectious agent are most promising. The first technical method, so called personal prophylaxis, includes measures which must be applied by the individual; while the second includes the responsibility of the community or of the public health department.

Personal prophylaxis- The only absolute personal preventive measure is continence. Complete loyalty between husband and wife should be stressed. This ideal, however desirable it may be, has its limitations. Anyone, who has a real knowledge of the emotional life of the people and the causes of the incitement to promiscuity, will not fail to perceive the growing tendency among the population, under the present economic and social conditions, to go for a full sex life before marriage. Once the fact is recognized, the principle of personal prophylaxis becomes real and urgent. It must be applied through education of the individual about the sources of infection and methods of prevention. If sexual contact cannot be eliminated by the individual, it is still within his power to exercise selective discrimination and to limit his contacts to sources of lesser hazards. There are certain available sexual partners who present a much greater risk of venereal infections than do others. Promiscuity, in contrast to selected sexual relation and the cheap prostitute, in contrast to partner who is only occasionally exposed, involve greater risk of infection and are to be avoided. Actual specific preventive measures are mechanical, chemical and chemotherapeutic. Mechanical protection in the form of a condom is highly efficient. Chemical methods of local disinfection have long been used with success in centre set up for the purpose. Effective and handy packets for individual use have been recently prepared and have found their way in the market. These individual methods can be applied to civilian population if the public is educated in their proper use and brought to a standard level attained under military conditions in the army. Chemotherapeutic prophylaxis is at present in its infancy and is limited to the use of sulphanilamide group of drugs by mouth for prevention of gonorrhoea and chancroid. Results of experiments are encouraging. However, in all these cases, it must be emphasized, surveillance to exclude any possibility of developing disease is essential. With the rapid developments in the preparation of new drugs, the potentialities in the field are very great and promising.

Public-Health Measures- Most public health programmes for the control of venereal diseases combine treatment facilities for the infected with the preventive programme. As compared to other fields of medical practice, where prevention has attained equal importance with treatment, venereal branch, it is regretted, is very much neglected. The importance of prevention and urgency of reforming rapidly the administrative organization to the same extent as in other branches of medicine could not be stressed more strongly. It is a matter of necessity, for the success of the scheme must depend on it. The care of the affected was the first responsibility; with the progress of time prevention become an accepted responsibility of the community and, therefore, to be dealt with by the public health authority. It seems logical that this must be the eventual future of the venereal diseases. This principle was actually practiced by the United States army in the European theatre of war where prevention of venereal disease was delegated to the Division of Preventive Medicine, and the treatment of these conditions to the Division of Professional Services. The scope of preventive programme for venereal diseases falls into three divisions. Epidemiological methods, its importance in defining the places for emphasis, and the points of attack have been already discussed. The programme of education on the basis of the finding of epidemiological experts promises the most in limiting the incidence. The general educational approach should endeavour to raise moral standard, build up character and self control of the general public, and foster equal responsibility between the two sexes. It should propagate ideas regarding the nature and gravity of diseases, that the continence and suppression of sexual desire is harmless and is only a matter of education and habit, that the use of selective discrimination and prophylaxis will reduce the chances of infection, and that the policy of cowardice to face the disagreeable truth demonstrated, in trying to hide the disease or reporting late for examination or treatment is dangerous. It should elicit public support on the value of notification. As in general public health, education, posters, movie-pictures, lectures, informal discussions in small groups etc are all useful. News paper publicity, talks on wireless and pictures are most valuable and excellent in the mass appeal. The problem is so urgent and important that no one who can contribute should remain inactive.

Specific methods of public education in the venereal diseases are directed essentially towards two groups, the medical profession and public health authorities. A coordinator well versed in general programme which has been agreed on, visits local health authorities, outlines satisfactory programme and makes specific suggestions in view of the local conditions. Success of this method in civil practice led the United States Army to adopt it as the basis for its programme. Specially trained medical officers and staff, together with special equipment, will be necessary to man the clinics. Specialists and special clinics have to be catered for because they alone can provide extra skill and care which a patient is most certainly entitled to expect.

Practice of preventive medicine and the education of the population in good health measures are bound to advance rapidly. The extent to which the social and economic factors contribute in the prevalence of diseases is becoming increasingly evident. Any factor which will tend to reduce the gap between the time when a boy or girl becomes sexually mature and the time when they can marry and support family at an earlier age will reduce the incitement to promiscuity. In the preventive measures the importance of substitutive activities and recreation centre must be recognized. Punishment as a preventive is totally futile.

In an attack on venereal diseases, all the resources of the community must be effectively harnessed. This will require change in public opinion, changes in economic conditions, and correction of innumerable social problems. However, there is no need to wait. Much can be done now. The example of Russia, where striking results were obtained in the shortest time in her campaign against venereal diseases, is before us. Equally striking results must be achieved in India. The statements of Popular Ministries, who are aware of the glaring need for progressive attitude and who support the view. “No individual should fail to secure adequate medical care because of inability to pay for it”, should go a long way in bringing about rapid and radical changes.

* The writer records his thanks to Lt. Col. Jelel M. Shah, I.M.S. for his suggestions for preparing this article.