MEASURES FOR CONTROL OF V.D

by Dr. M. P .Vora

Indian Medical Record

A monthly journal of Public Health, Tropical Medicine & Surgery etc.

Volume LXXXIII, Number-7 of July 1963

Pages 103-107

Venereal diseases are shrouded in the fog of ignorance, superstition and prejudice. Though they constitute a major public problem, they are relegated to a position of no importance. Our V.I. Ps go about the country, presiding over or inaugurating medical or health conferences and exhibitions, but never refer to the problem of V.D. in India. Not unusual, is the absence of any reference to the incidence of V.D., among the industrial workers, in the last annual report of E.S.I Corporation. While campaigns against infectious diseases such as small-pox and T.B. have been launched with some success, very little has been one to control V.D. in the country. Today, the incidence of V.D. is on the increase especially in the younger age-groups, and poses a great danger to Public Health. If the preservation, prolongation, comfort and happiness of human life, are the ultimate goal of medicine, can we afford to ignore this problem?

One suspects that prudishness or synthetic morality of the authorities concerned, is partly responsible for facing the facts, however, unpleasant they may seem. Ignoring the existence of V.D. or the tactic avoidance of the subject will not be helpful. On the contrary, it will only make the work of the public health authority more difficult. It does not seem to have been realised, that the basic causes of venereal infection are social and individual, and that a number of diseases, have their origin in the venereal infection. Hence it is all the more necessary that we pay timely attention to this problem.

A careful survey of the present situation, makes one disheartened at the sorry state of affairs, with regard to V.D. in the country. The authorities have neither a clear-cut policy in regard to V.D. nor well-planned and organised measures, to tackle their control on the scientific basis. Existing facilities for the diagnosis, treatment and control of V.D., are grossly inadequate, ill-planned, unorganized and touch not even the fringe of the massive problem. Indifference towards it is certainly beset with grave dangers. Authorities seem apathetic, and continue their haphazard policy, violating even the basic rules and needs of V.D. relief and cure. The sum total of all this, is a shocking waste of precious labour and money, without nearing our desired objective.

Whatever few clinics, we have, are in the urban areas. No facility what-so- ever exists in the district or mofussal towns or villages. Most of the existing clinics offer an uncongenial atmosphere and are working at a grave disadvantage, for the want of proper and suitable accommodation, equipment and adequate staff. Proper methods of diagnosis, case-tracing, case-holding, education of patients, record-keeping, tests of cure and surveillance,- the most important procedures in the management of venereal diseases, - are generally neglected. In most clinics, No attempt is made for accurate diagnosis by means of modern scientific methods or contract investigation, or to bring under treatment the sources of infection.

Besides, V.D. clinics receive step-motherly treatment from hospital authorities, who are generally ignorant or unsympathetic, to the needs of the clinic. Very often a member of the staff, trained for a specialised job, is suddenly transferred to another department, without either the knowledge or consent of the venereologist in charge. Such procedures create problems leading to frustration and inefficiency. If the clinics are to function properly and progress efficiently, it is essential that they should be under the direct control of the central authority, say a Directorate of Venereology. Such a central authority alone, can do justice to the needs of a clinic, and remove difficulties, which are unavoidable in the present set-up.

As things now stand in the medical and public health administration, venereal diseases come under the Surgeon-General of a State. This is a very unsatisfactory and anomalous situation, which needs immediate correction. There are many obvious reasons, for not burdening the Surgeon-General with additional responsibilities which, by the very nature of their peculiar problems, he will be unable to fulfill. The obvious course then is to establish a separate venereal authority, the Directorate of Venereology, and bring all problems connected with V.D. under control. And the State Governments, con-jointly with the Central Govt., must set up a separate division, say, a Deputy Directorate or a Regional Directorate of Venereology, venereal disease control, as part of the State and Central Health Organisation. Under such a central authority, efforts for the control of V.D. can be adequately coordinated at the State and the Central levels, without which, it will never be possible to adopt coherent and integrated measures, and enforce them throughout the country. To encourage the planned and organised growth of V.D., institutions, and to ensure their smooth running, a Directorate is of the first importance. Planning without a machinery to carry out plans is quite futile. The appointment of the advisor in venereology to the Central Government, made in 1957, is surely not an adequate answer to the complex problem. It has not helped to change the picture materially.

Venereology and dermatology are not normally to be combined in one unit. Two separate chairs for these, need to be instituted in every teaching hospital and medical college. This by itself, will do much to maintain high standards of efficiency. Unhappily, this important point has been overlooked in the new medical colleges, started recently, and many colleges and hospitals in the country, continue to have a combined department for these two specialities. In the opinion of the experts, the standard of work done in a combined department, is far from satisfactory, and it is commonly the venereal work which suffers the most. It is necessary now, therefore, to create a separate venereal department in every general hospital. Are not the venereal patients entitled to have the benefit of highly specialised care?

The institution of a diploma or degree in venereology, on the model adopted by the University of Madras, will alone help us, to achieve and maintain, high standards of learning and efficiency, and guarantee steady progress. It is therefore, essential that the universities in the country introduce a post-graduate diploma in Dermatology and Venereology is not a very happy or inspiring one. This has helped to raise the standards in neither speciality.

In spite of the growing number of new medical colleges, there has not been a corresponding increase, in the number of good venereologists in the country. It is for the authorities concerned, to give encouragement, incentive, social status and prestige to this speciality, as is done to other medical specialities. This will attract new talents to the practice of venereology, which is so essential for the solution of the problem. Today, a venereologist must form a part of the comprehensive medical team, rendering invaluable service, in the relief of human suffering.

To ensure regular supply of competent practitioners in the future, the training in venereology for medical students, needs to be improved and enhanced by introducing a new curriculum.

A three month course in the practice of venereology needs to be started, preferably at the institute of venereology, for the benefit of general practitioners, so that they may gain insight into the management of venereal cases, and may be able to discharge their responsibilities ably. In detecting V.D. the G.P. is the key figure, for he is usually the one to meet them early. A large number of V.D. patients seek treatment from general practitioners, but the standard of management is generally not upto the mark. Although, the private practitioner has always figured prominently in V.D. control thinking, he is, in general, in no position to become a part of the control team, in a countrywide effort. For all this, the authorities must develop appropriate procedures to be completed by the practitioners, who undertake to treat V.D.

The provision of free and adequate diagnostic and treatment facilities, for all infected persons, is am integral part of V.D. control programme, and no scheme, set up for the purpose, will be effective, unless the financial responsibility is shouldered by the State. Particular attention has to be given to finding out the sources of infection, and to holding on to the defaulters in the treatment, till they have been properly tested and declared cured.

While planning some new medical activity, such as a hospital at district or town level, the need of a good venereal clinic is to be borne in mind. The basic needs of a clinic must be fulfilled to make it efficient, attractive and popular. They are:

• A venereal clinic must have invariably be located in, and be a part of the ordinary out-patient department of a general hospital. It must not be separated and distinguished from it, and must go under suitable name as “social diseases” or “special diagnostic centre”, to avoid stigma, generally attached to V.D. Moreover, this saves the inconvenience to the sick going from one place to another in cross references.

• It must have adequate and suitable space to ensure the privacy and separation of the two sexes, and to carry out its different functions with utmost conveniences, economy and efficiency. Separate entrances and exits, waiting and treatment rooms for males and females are essential.

• It must have an adequate staff and technical personnel. It needs to be in charge of a full-time salaried medical officer, who has undergone an intensive course in the practice of venereology. No transfers should take place without suitable substitutes to carry on regular work.

• It must have properly equipped laboratory, where necessary diagnostic procedures, can be carried out speedily under the supervision of the venereologist. Laboratory examination for accurate diagnosis of V.D. is an obligatory procedure before the treatment is instituted, and the work of contact investigation can be undertaken.

• It requires at least two social workers, one male and one female, to carry out the work tracing the contacts of an established case, and to keep track of cases, when they default, as often happens, either in the treatment or the follow-up tests. The investigation of the contacts of an established case of V.D. is now a well recognised practice all over the world and cannot be neglected.

• It must maintain standard records for each patient. For this necessary books and services of a trained clerk are required items. Without proper records, the follow-up of cases needed to declare these cured and the collection of statistics is impossible.

• It has to be open both in the morning and the evening so that the patients can attend whenever they find it convenient. No patient should have to wait more than half an hour, either for consultation or treatment at each visit. To reduce the pressure of work on the clinics, it is advisable to permit the practitioners to have at these clinics, free diagnostic facilities and consultant’s advice in respect of their patients.

• It must maintain a prophylactic centre open day and night. It has still its place of importance, not-with-standing modern methods of treatment. Here, prophylaxis and education of the patients and the public in respect of V.D. prevention, should be made freely available.

• It requires a small section for education of the infected and the public in general, and to carry out anti-venereal propaganda. Ignorance of the public is the greatest obstacle in the control of V.D., and must be dispelled by intensive education by means of posters, cinema, radio, press and lectures. Educational programmes for the public must be broadbased, covering all aspects of V.D., and must be brought to bear in the life of every youngster.

• Each clinic needs to be provided with a mobile clinic or van to cater to the surrounding areas, where clinic facilities are not available. A given area should be regularly covered by these mobile clinics.

Monthly returns from all clinics, and practitioners treating V.D. must be made compulsory. This will help the authorities to collect the V.D. figures, establish incidence of infection, and to direct effort according to the need of each locality.

Co-operation between the venereologists and specialists in other branches of medicine is indispensable, and must be ensured by appropriate means. A good number of V.D. patients find themselves admitted in medical, surgical, ophthalmic, E.N.T., mental, or gynaec wards for various complaints, the origin of which is in the venereal infection. Without proper cooperation among them, it will be impossible to determine the incidence of V.D. and its complications.

In curbing V.D., the Scandinavian countries rank first among the advanced nations of the world. There the law requires the reporting of V.D. cases, obliges the infected to receive treatment, penalises the deliberate transmission of infection to others, empowers the health authorities to find and bring under control all sources of infection. The premarital examination of the persons intending to marry, and their blood tests are compulsory. Anti-natal blood tests in pregnant women are obligatory. It is high time that we have similar legislation to control V.D. in the country. In addition we must deal more sternly with quacks and fraudulent healers, who advertise cures, and chemists who sell antivenereal drugs to the public without a doctor’s prescription.

Further, we must strive to improve socioeconomic conditions of the people, to provide healthy recreational facilities for the youth, to promote marital harmony among the married and to reduce, if possible, the gap between the time of sexual maturity and the time of marriage. Punishment as a preventive is futile.

It is desirable for each State to have:

• A venereal authority or division which will work in cooperation with the Central Venereal Authority.

• A Central Laboratory where advanced work and research of V.D. can be undertaken.

• A school for training hospital social workers, venereal diseases forming a part of their studies.

• An Institute of Venereology, at which the varied personnel required to man the growing number of venereal clinics, can be given training. Doctors, nurses, social workers, technicians, dressers and clerks etc. will receive proper training in the management of V.D.

• Mobile Clinics or Vans for the rural population. Regular tours being arranged to cover a given area.

Venereal diseases may not be brought to heal in our time. It will certainly not be so, if we fail to recognise them for what they are. They are as old as Venus, and like Venus they will always be with us. To keep their incidence at the lowest level, we must maintain an external vigilance. Their control depends on a vigorous prosecution of all the elements of the programme: diagnosis, treatment, case-finding, case-holding, anti-venereal campaign plus safe sex education. The problem requires to be tackled on the national scale, our attitude towards V.D. needs to be radically changed, and our policy in regard to venereal diseases must be re-oriented, in the light of modern knowledge. It would be infantile to persist in a policy which has failed.