IMAGE OF INDIAN VENEREOLOGY

by M. P. Vora, M.B.B.S., D.V.D. (Major Rtd.)

Current Medical Practice

A Monthly Journal Devoted to Modern Medicine and Surgery.

Volume No- 15, Number – 11 of November 1971.

Page No. 1033 to 1036.

Venereal diseases pose as an urgent and serious public health problem. Their rates of incidence and prevalence are alarmingly high in the country. According to the former Union Health Minister, Dr. S. Chandrasekhar more than 20 million fresh persons suffer from V.D. every year. For every case that comes to light, there are at least 20 or more undetected cases in the society. Such a high rate of incidence combined with peculiar conditions that prevail in the country, makes V.D. the gravest public health hazard. However, the medical profession and health authorities are reluctant to group them as pandemic or highly epidemic diseases. On the contrary, V.D. is still considered less serious and not worth attention. The number of infected with V.D. swells with ever-increasing rate as there are no organised efforts to control them. There is sufficient justification to treat them as a national health problem of great magnitude. If this scourge is not checked in time, these diseases are bound to spread sevagely and in ever-widening circles.

Medical services for these diseases are scanty, variable and generally very unsatisfactory throughout the country. Venereology is recognised in a few hospitals and universities; while in majority of other places, it is often incorporated with dermatology. In most of the medical educational institutions, venereology does not find a place in the list of medical specialities. This has led to a good deal of confusion and deterioration in the standards of medical education and training in venereology and medical services to venereal patients.

Of all the subjects taught in medical colleges, venereology is perhaps the most neglected one. Less and less time and efforts are being allotted to the subject in already full and expanding curricula of medical colleges. The way venereal patients are dealt with, at present, is nothing short of quackery and amounts to sheer mockery. Most of the fundamentals in the management of a venereal case such as human attitude towards the sick, proper clinical examination, early diagnosis, its confirmation by laboratory tests, contact-tracing, education of the patient with regard to his or her disease, adequate treatment, case-holding, record-keeping and tests of cure are rarely performed even in the so-called teaching medical institutions. This is shocking but absolutely true.

It is considered necessary to have at least one fully- equipped and staffed V.D. clinic for a lac of population. Assuming there are roughly 50 million cases yearly, we would need about 6000 clinics to meet the present requirements of the population. As per Government’s belated announcement, 201 clinics were established in India during the first three Five Year Plans, and five headquarter and 75 district clinics are proposed to be started in the fourth Five Year Plan. However, there is no mention of reference laboratories, which play an important role in the practice of venereology. When will the target be achieved at this rate and speed? It is a matter of great regret that most of the clinics established are in name only without adequate drugs, laboratories and so on. Venereal diseases clinics as a rule do not see better days anywhere. Although they are set up at the hospitals, they somehow fail to remain in the hospitals, being crippled with any amenities, funds, staff, space etc. In general, there is no provision for inpatient’s care resulting in neglect of clinical instructions and demonstrations for medical students. If one were to compare a V.D. clinic with any other hospital department, the most glaring and contrasting picture would be obvious. Long delays, humiliation, lack of privacy and difficulties in cross references are common accompaniments of attendance at these clinics, which work for a few hours in a day or on the alternate day. It is necessary to extend the hours of V.D. clinics by introducing additional evening sessions to reduce the morbidity rate. It is a known fact that venereal patients, if they happen to seek medical aid elsewhere, are generally defined proper examination, correct diagnosis, adequate treatment and follow- up tests of cure. From what has been said, one can easily imagine the practical utility of these clinics. Even in place like Bombay, which can boast of many fine hospitals, nearly 90 per cent of the venereal patients have to go without proper medical care, leave aside smaller towns and villages, where elementary medical facilities are rarely available. It is an insult to the venereal patient to talk of providing specialized medical services for everyone in the country when most of the hospitals are without venereologists and venereal departments. The policy of merely adding to the number of V.D. clinics without adequate staff, specialists, equipment, teaching curricula and environment can only lead to increasing wastage of precious resources. What is now urgently required is a process of consolidation and plan to improve the quality and content of the existing clinics. But no one bothers.

The result of all these is that few medical students can hope to get themselves properly acquainted, during their studies, with the basic knowledge and facts in the diagnosis, treatment and control of V.D. The reasons for all these ills is not difficult to find. Our out-dated and irrelevant concept of “dermato-venereology” patronized by the health authorities and medical educationists in the country is mainly responsible for this sorry state of affairs. Dermatovenereologists, frankly known as dermatologists usually lack keenness and interest in venereology and venereological work becomes a neglected subject. They conveniently forget the fact that they have been appointed to diagnose, treat and control the spread of V.D. They utilise most of the hospital facilities, amenities, staff, funds etc. for the dermatological work. To them retention of their own hold on the subject means everything. An uncommon case of dermatology creates a great sensation and excitement but many unusual cases of V.D. fail invariably to evoke a similar response. The effect of this antiquated concept is that venereology is relegated to the background and venereological work suffers a total eclipse. Take the example of the best known V.D. clinic in the world, directed by John Strokes at Philadelphia. No sooner its director was succeeded by an able dermatologist than the subject of venereology was eliminated and venereological work suffered a total extinction. Another equally famous clinic at John Hopkins Hospital met with a similar fate. The subject of venereology was swamped and a generation of high-powered dermatologists emerged to the detriment of education and training in venereology and medical services to venereal patients. But we seem to learn nothing from these examples.

There is perhaps no other branch of medicine as that of venereology which is so intimately interwoven with public health so as to be inseparable from it. However, venereal diseases rarely constitute a part of programmes of the public health authorities. Venereal diseases are a sign of social disorder and require strengthening of social medicine with clinical medicine. In venereology, a special emphasis is placed on every case to find out the source of infection and contacts so as to control the spread of V.D. That is why a venereologists is also a public health worker. Very few are aware of this duel role the venereologists have to play. Department of Preventive and Social Medicine ought to have on the staff, persons well qualified in venereology to offer and extend facilities and special studies relating to epidemiology, social and preventive aspects of venereal diseases. The writer has still to come across an example of this type in the country.

Despite continued threat and epidemic out-break of V.D. in the country, venereal diseases have miserably failed to secure recognition for propaganda and increasing general awareness. Public health authorities are reluctant to meet their obligations or offer passive resistance to the co-operation of any kind. Some voluntary organizations like the Association for Moral and Social Hygiene and Bombay Social Hygiene Council play some important role in this sphere but their activity is limited to the city of Bombay. Vast masses still remain ignorant and uninformed about V.D.

Take the question of establishing a university chair in venereology. It is overdue and one supposes it will not be long delayed in view of the direction by the conference of the deans of medical faculties of all universities in India. This will offer true guidance and inspiration and the subject will derive greater attention than the present. Emphasis will continue on scientific diagnosis, adequate treatment and control of V.D. To trace and examine potentially infected contacts and thus to reduce the morbidity rate are sufficient justification for making this a separate and independent speciality and keeping it so. Those who advocate or persist in the concept of dermato-venereology must look more deeply into the matter to realise the mistake. But we seem to be deaf and blind to the problem.

Training in venereology and venereological work is of utmost importance. But it does not get the attention it deserves. Virtually there is no provision for training and very few hospitals and Medical Colleges offer training facilities either to medical students, intending specialists or general practitioners in medicine. Lack of space, insufficiency of staff, equipment, and want of devotion to the subject have their repercussions. There are two training centres in India- one at Safdarjung Hospital, New Delhi and other at Madras – to train medical and para-medical personnel. But their functioning is still to reach satisfaction and acme. They have their own difficulties which commonly haunt V.D. After a great deal of persuation, Maharashtra State opened the third training centre in Bombay some 13 years ago. But its functioning has been hampered at every step by numerous obstacles. Instead of humming with intense activity, it presents a deserted and inactive look. One has reason to believe that there has been deliberate attempts to throttle it from its inception and create conditions that would render it totally ineffective. Training facilities for general practitioners are meagre. In the city of Bombay, free refresher courses are regularly held from time to time under the joint auspices of the Association of Moral and Social Hygiene, the V.D. Advisory Committee, Maharashtra State and the Municipal Corporation of Greater Bombay. Judging from enthusiasm and interest of general practitioners, they have become quite popular and attractive. Medical conferences or seminars arranged rarely include talks on V.D. Medical societies and associations, although possess sections in every medical and allied speciality and subspeciality, through which they periodically conduct meetings and clinical demonstrations, they rarely include or invite the speciality of venereology. Reading or publishing articles on venereology is uncommon. All this has precluded high standards in the subject and killed the desire for knowledge.

In the matter of appreciation of work and distribution of awards or honours, no other speciality is known within hospital services except venereology, where the percentage of these has been so negligible. The writer is not aware of any instance of recognition, honouring or awarding a teacher, clinician or writer in the speciality.

Research is out of consideration as far as the subject of venereology is concerned. There are numerous projects in venereology needing immediate study and investigations. But nothing is possible due to lack of finance, space, staff, and modern amenities. One has, therefore, to depend on other nations’ observations. For one reason other, funds are not readily available for venereal work.

Though the number of specialist in various branches of medicine has considerably increased during the last few years, the number of venereologists has remained static or rather dwindled sharply. It is often said that there is dearth of teachers, clinicians and trained personnel in venereology; and the subject does not attract young physicians. This is true to some extent; but there are many valid and immediate reasons for this. They must be identified and quickly liquidated. When venereology does not exist in the list of specialities, how does a young doctor know if it is worth setting foot on a particular ladder? After training, he is sure to find no vacancy at the end. Besides, step-motherly treatment, lack of appreciation and encouragement, discrimination in matters of promotion recognition or honours, absence of proper guidance, associated stigma and prejudices etc. are sufficient to freeze anybody’s enthusiasm for the speciality. If we desire to make some headway and create interest in the subject, venereology must get recognition and its due importance in medical training, education and services. Unnatural and uneasy link that exists in venereology and dermatology ought to end quickly. To meet the present shortage of personnel, the writer would urge employment of retired men. But the authorities have shown least interest in utilizing the idle man power as far as venereologists are concerned. They have still to learn to use the available expertise for the good of the nation. Bombay can be proud of some fine and experienced teachers and clinicians in venereology, the entire credit for which goes to the Grant Medical College and its attached J.J.Hospital, Bombay where venereology has been recognised as a separate speciality for over last thirty years. These men have given their best to the despised and neglected subject and left it far better than they found it; and thereby, earned the respect of their colleagues. The same does not hold good in the case other medical colleges and their attached hospitals.

In the United Kingdom, venereology is recognised as a separate and independent speciality and venereologists work exclusively in their own field. This has helped to build up an ideal and comprehensive venereal diseases service. Its effects have been remarkable and applauded with praise. Because of the enlightened and dynamic policy, British venereology can be accepted as an ideal example to follow.

In our country, venereologists have become “outcasts” in the higher levels of national health, medical education, planning and management. There is urgent need to give them due status and position in spheres of national health, medical education and training. Will our health authorities, Medical Council and educationists think over the matter and correct the inept situation? It is high time that venereologists are considered as a part and parcel of medical profession and given due consideration to their views on that subject. Sooner they do this, better it would be. It would be a great mistake to reject scornfully their most sensible plea for the recognition of venereology. On this very fact depend progress and advance in the subject.