QUALITY OF MEDICAL SERVICE TO VENEREAL PATIENTS

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

Current Medical Practice

A monthly journal devoted to modern medicine and surgery

Volume 17: Number – 12 of December 1973.

Pages 545 to 549.

Indeed, it is a sad confession to make but the truth must be told, however unpleasant it may be, The standard and quality of medical services to venereal patients has remained disgracefully out of date and discredited. In this observation, there is not the slightest exaggeration. The quality and the content of medical services to venereal patients has been a frequent target of attack lately. It takes a kind of perspicacity and discernment to bring to the public notice the glaring defects in the health care for venereal patients. This critical review may come as a great shock to the public. But it should be welcomed and examined carefully for it has sane and constructive intention. The scathing criticism has appeared, from time to time, in the press also and come from local as well as foreign experts, who happened to survey conditions in the country. The standard of health care received by these patients either from general practitioners in medicine or public or private hospitals has not been upto mark and far from satisfactory. Nay, the writer would call it not only incompetent and useless but also most dangerous. Its grave and devastating impact on the health of the sick, his family, and community in general and national economy has been totally ignored. All ways of judging quality and standard of medical care for V.D. patients show distinctly dismal picture. Improvement or excellence is sought through criticism. One has to become accustomed to scrutiny of one’s work by colleagues, self-audit and audit by others. It is most needed and least welcomed. But it must become a habit, if one is to improve one’s standard and efficiency.

New Developments

A great paradox in medical progress is the steady and sustained rise in the incidence of venereal diseases despite the recent advances in the methods of diagnosis, treatment and epidemiology. The overall picture of the V.D. control programme in the country is very disappointing, ill planned and unorganized. The most important and striking social development of the last decade has been the change in the sexual attitudes and behaviour of the large section of the population, greater freedom and independence of young girls and women. There has been an abrupt and sudden swing in public attitudes in favour of sexual activity in all its forms. Along with this, is the greatest upsurge of venereal infections, ever known during the peace time? However, medical services and personnel associated with venereal work have not kept pace with or have not been fully aware of these sweeping alterations in public attitudes. Today, an increasing number of people regard venereal infection as an accident of sexual activity to be dealt with rapidly, efficiently and then forgotten. On the other hand, most of the patients in our country are quite content to be relieved of their symptoms only. Their gross ignorance about these infections is evident.

Specific failures

These can be cited ad infinitum and ad nauseum to provide proper medical services to venereal patients. Nearly cent percent failure or non- performance is usual:

• Refusal to appoint venereologists on the teaching staff of medical colleges and on the panel of specialists for the hospitals.

• To provide proper and adequate medical education and training in venereology for medical students and intending specialists in the subject.

• To use proper laboratory tests both for the confirmation of diagnosis and cure of the infection, when the treatment is over. Assumption of either diagnosis of cure of V.D. must not be allowed to make rational of specific chemotherapy meaningless.

• To trace, investigate and treat contacts of established or known cases of V.D. The proper management of V.D. must include investigation treatment of contacts.

• To prescribe proper drugs in adequate dosage for a sufficient period or the use of improper drugs.

• To ensure completion of treatment and follow-up tests of cure.

• Maintain proper records and statistics and to report them regularly.

• To provide social workers, health visitors, specialists, receptionists, nurses, technicians, etc. for the established clinics.

• To provide sufficient or adequate finances.

• To provide right kind of clinics.

Most of the clinics established in the country are only on the paper. Their organisation, set-up, accommodation, staff, equipment, work, procedure etc. leave very much to be desired. Unsympathetic and inhumane attitude, inadequate and inconvenient timings, inordinate delays, lack of privacy, inefficient or insufficient service, failure to trace contacts to carry out laboratory tests for confirmation of diagnosis and cure, absence of trained personnel, want of modernization, meager finances etc are conspicuous by their presence. These clinics furnish unreliable statistics and persons in charge show no dedication or responsibility, sustainability, dependability and qualifications are not of primary concern. Hence efficient human service is rare at most places. It is now increasingly realised that management of V.D. can no longer be left to amateurs but must be entrusted to professionals.

Urgency of Medicare

Venereal disease in one form or another is very common in the practice of almost every general practitioner in medicine. It is most potent and frequent cause of illness and must involve men, women and children of different age. Its manifestations may be obvious or hidden or so diverse as to cover the entire range of medicine. It is not uncommon for these patients to get themselves admitted in medical, surgical, E.N.T., ophthalmic, gynaec, cardiac, neurologic wards for various complaints, the origin of which is uncured venereal infection. However, coordination of specialists in other branches of medicine is hard to come. The general practitioner in medicine is the back-bone of health services and is first to be approached for medical advice and help. His main role is and must always be that of primary diagnostician and therapeutist in medicine. It is vital to preserve him. However, his education and training in venereology and venereal work is very inadequate and marginal. It would not be far from truth, if the writer was to say that he has had no educational and practical training in the subject. He has usually no laboratory facilities at his disposal either for the confirmation of diagnosis or “cure”. During his study, he has not developed a co-operative attitude towards the control of V.D. He has hardly any time or inclination to trace the contacts of the patients he treats. Most of the patients receive what is called “Therapeutic approach”, “Hit-or-miss”, or “Shot in the darkness” therapy, without any recourse to the basic principles in the management of V.D. This trend, which is in vogue all over the country, offends very normal requirements and has dangerous potentialities. In fact, the way venereal patients are dealt with is nothing short of quackery and amounts to mockery. Humane attitude, proper physical examination, correct diagnosis, its confirmation by laboratory tests, education of the patient with regard to his or her infection investigation of contacts, proper and adequate treatment, follow-up tests of cure, record-keeping etc., the very basic procedures in the management of V.D. are rarely done even in the so-called teaching medical institutions. This is very shocking but absolutely true. These mouldy features of medical services ought to have been discarded long ago, but they still persist with remarkable tenacity. It is simply criminal to relieve merely symptoms alone, in contravention of the precepts of therapeutic rationality, when there is an effective way to deal with the cause of disease. These flagrant examples of medical negligence and scandalous frauds perpetrated on the ignorant must cease immediately. The dangers of unskilled services are obvious in the steep rise in the incidence and prevalence of V.D., incalculable human sufferings needless deaths, disabilities and financial loss. Even to this day, no remedial measures are contemplated to correct the critical situation. It is no wonder that elite public has little confidence in the quality and content of medicare for venereal patients. Especially, when the incidence of V/D. is very high, the most important task of any physician is to recognise these diseases in the very early stages treat them properly and adequately and contain their spread. But is he or she in a position to fulfill these stipulations and discharge responsibilities? No. How can this inability be condoned or excused? Doesn’t this invite law suits for medical negligence or incompetence?

Education in venereology

There is curious ambivalence, in the country, regarding the place of venereology in the medical education. It is not realised that the quality of medical services depends on proper education and training in venereology for medical students. Unfortunate as it is, the curricula of most medical colleges in the country totally neglect the study of V.D. though of utmost importance. This has naturally resulted in the deterioration in the teaching and training of medical students and poor attendance to venereal patients. A few remarks of different authorities on the subject will not be out of place:

Dr. B.A. Daruwala, noted teacher of the University of Bombay has to opine that, “Even those awarded the double post-graduate qualification in dermatology and venereology is unadulterated dermatologists with no knowledge and little interest in venereology”.

Dr. R.V. Rajam, authority from Madras said, “In most of the teaching hospitals, the standard of organisation and performance of teaching and medical care of V.D. is nothing to be proud of”.

Dr. C.S. Nicol (1971) the British expert, during his visit to different centers in India, could not fail to notice vast difference in medical services rendered to venereal patients by separate departments of venereology as against those by departments of dermato-venereology (very common practice in the country). He was frank enough to express his dissatisfaction of the Indian system of specialising in dermatology and venereology jointly. He said, “If India is to contain its critical situation and prevent future increase in V.D., which will occur in the next decade, she must maintain venereology as a separate subject in the field of medicine both in the undergraduate and post0graduate teaching at her Universities and must establish institutes of venereology and laboratories in every state”.

Dr. M. Candaw, the last W.H.O. Director General (1973) said, “Endemicity of V.D. in the world is chiefly due to professional and public laxity and ignorance. The main reason for lack of action is inadequate health education of the public coupled with the fact that medical and other health personnel often lack familiarity with venereal diseases or underestimate their value. Sex education too is deplorably inadequate”.

Even the deans of medical faculties of Universities in India at their conference held at Bombay in 1970, were constrained to deplore the sorry state of affairs with regard to teaching and training in venereology and demanded the recognition of venereology as a distinct and separate speciality.

The editor, The Times of India, Bombay (nov.7, 1971) writing editorially on ‘The V.D. Scourge’, wrote, “Medical educationist will do well to shed their old ideas”. Deprecating the tendency to link venereology with dermatology, he said, “It is high time that the study of V.D. is entrusted to a separate department and a separate chair of venereology is established in universities”.

Bombay Social Hygiene Council, “a solid body of experts in all fields of venereology to inform, orientate and advise”, which celebrated its Golden Jubilee in 1968, had by its resolution of 1958, demanded unanimously recognition as two separate specialities and condemned the tendency to group them together either in hospitals or medical colleges.

A similar demand was made by the V.D. Advisory Committee of Maharashtra State in 1967.

Failure to act

However, all these remarks have failed to evoke a response of the bureaucrats in the country. Delays in action have now become endemic and perhaps irremediable. A university chair in venereology is essential and one ardently hopes that it will not be long delayed. This will offer true guidance and inspiration and the subject will receive better attention than at present. Emphasis will be on the scientific diagnosis, proper treatment and control of V.D. Besides, it will help to make workers take their art and craft seriously and initiate research. However, neither Indian universities nor the Medical Council Of India, whose elementary duty is to maintain proper standards of medical education and services, are least inclined to consider this progressive measure and effect appropriate changes in their policy with regard to venereology. Not only that, the Medical Council has the stupidity to give a fresh lease only recently, to its out-dated and ill-conceived policy of dermato-venereology”. What is worse, even the official agencies managing E.S.I.S., C.H.S., public and private hospitals are found to suffer from irrational ideas of Victorian prudery and are unwilling to appoint qualified venereologists on the staff and provide proper medical services to venereal patients in their establishments, though this can be done easily and without much extra financial burden. This continual apathy is inexplicable. As the result, more than 90% of venereal patients have to go without proper medical care even in the city of Bombay, which has many fine hospitals. Needless deaths and irreparable damage to vital organs that occur due to incompetent medicare could not be imagined. The survey of industrial workers in Bombay has revealed 12% sero-positive rate, which speaks for syphilis alone. There are many other venereal diseases, which are more frequent and common than syphilis. The leading cause of disability among workers is syphilis according to the U.S. Public Health Service Study. However, the committee on the prospective planning of the Employee’s State Insurance Scheme could not spare a word on venereal disease services to employees at the time of its deliberations. It is a matter of great regret that nothing is done to meet employee’s basic requirements of health care (venereal), though they contribute towards the medical services. Isn’t it the fundamental concern of the Welfare State to ensure good health of the citizens?

Adequate and proper education and training in venereology for medical students, general practitioners and intending specialists ought to be provided in all teaching medical institutions. In fact, this must go high in the priority list. However, most of the medical colleges and universities remain totally unconcerned. There is no doubt that things would not have come to the present sorry state but for the instant inaptitude of medical educationists, health authorities and the Medical Council of India. One hopes that the speciality of venereology will be established firmly and perpetuated by regular appointment of venereologists at all general hospitals and the knowledge of sexually transmitted diseases - viral, bacteriological, serological, social and epidemiological - will find rightful place in the teaching and training of medical students. It makes no sense to dent venereology its due and rightful place in the medical education training and planning health care.

Remedies suggested

• Recognition of venereology as an independent speciality and entrusting the study to a separate department and chair.

• Establishment of training centers and reference laboratories in every state.

• Vocational training programmes for all categories of workers such as doctors, nurses, social workers, health visitors, laboratory technicians, statisticians etc to improve their skills.
• Employment of trained personnel and regular supervision and appraisal of the work and departments.

• Provision of adequate staffs, equipped laboratories.

• Refresher courses for general practitioners, encouraging their contacts with clinics and specialists. Their frequent association with venereologists and venereal clinics are undeniably helpful in raising standards and quality of work.

• Regular seminars, lectures, demonstration and audio-visual instructions.

• Distribution of recent literature in the subject.

• To offer incentive, awards and grants etc. to encourage those who are really interested in the subject.

• Coordination between the states and the centre health authorities.

• Adequate finances and

• Professional standards review organisation consisting of experienced venereologists to police clinics and their work.

Conclusion

The quality of medical service to venereal patients has remained out-dated, inefficient, and insufficient to the determent of national health, happiness and economy. Attempts must be made to improve it in consistence and consonance with modern norms. All that we have done so far is to shut our eyes, ignore the serious problem and learn to live with it in a passive, non-dynamic and fatalistic way. Such callousness, apathy and total disregard for the public health and welfare would be rare to find anywhere. It is sad to say that ignorance and prejudice concerning V.D. is the world’s third most prevalent infection, its importance is underestimated or neglected. It is, indeed, a sad commentary on our inability to move with the times and keep pace with scientific and technical developments. It is essential to call for a determined crusade against V.D., if the nation is to survive the challenge of time.