PRESSING PROBLEM

by Dr. M. P. Vora

The Social Service Quarterly
The Organ of the Social Service League

Volume No. LIII, No. 2 of October 1967

Page No. 59 to 65

Of all the social ills of man, the least confined, the least manifest and the least likely ever to be static are venereal diseases, which constitute the most dangerous hazard to public health and happiness with heaviest impact on our national economy. Accurate statistics regarding V.D. are non-existent in India. However, some idea of the wide prevalence of this scourge can be obtained from different authentic sources.

At the St. George’s Hospital, Bombay, where accurate records are maintained the figures clearly show a steady rise in the incidence of these diseases during the last four years.

Don’t these figures show an alarming state of things with regard to venereal diseases? The prevalence rate of syphilis alone for the country as a whole could not be under 10%of the population; besides, there are other venereal diseases such as gonorrhoea, chancroid etc; the incidence of which often exceeds that of syphilis. The most of the cases are in a highly infectious condition and fall in age group of 18 to 35. According to the survey conducted by WHO and UNICEF, the incidence of V.D. in India is one of the highest, and Bombay ranks among the ten worst affected cities in the world. Recently, this staggering fact was confirmed and a grave warning was sounded about the further increase in the not too distant future by Dr.T.Guthe, WHO Chief Medical Officer for Communicable Diseases. He aptly described the situation as an iceberg of which a small fraction is visible. The prevalence rate of V.D. in Western countries like U.K., U.S.A. and France is often less than one percent. The economic loss to the country from these diseases is beyond estimation. However, no one wants even to talk about them.

NEED URGENT ATTENTION

Patients with venereal diseases and their problems need an urgent attention. Venereal diseases are the most potent and frequent cause of illness; they usually pass on from person to person often without knowledge. Their influence on good breeding, premature death, disablement and national economy is not sufficiently known to the larger section of the public. It is, therefore, of the utmost importance to plan in an organized way for their control at the national, state, district and town levels. Haphazard measures are bound to fail miserably. To neglect these patients- as is done now- is to neglect national health, happiness and prosperity.

It is essential to establish a separate venereal authority, The Directorate of Venereology and entrust it with all problems connected with V.D. such as planning, establishment of clinics, deciding the minimum criteria regarding equipment, accommodation, and staff for a clinic, posting of personnel, supervision of clinics, adoption of uniform policies and their application all over the country, collection of statistics and to provide services tailored to the needs of a particular area or situation and finally to advise the health authorities. And each state must set up a venereal division, the Deputy Directorate of Venereology as a part of the Central Health Organization for the purpose.To encourage the organized and planned growth of V.D. institutions and clinics and to ensure their smooth running, such a step is of prime importance. Without such a central authority coordination of efforts, adoption of uniform policies and their enforcement throughout the country can never be possible. It will be possible then to establish rapport and understanding which would give a unity of purpose and sense of direction both to the centre and the states alike. Importance of such a central authority capable of enforcing uniform policies with regard to V.D. throughout the country cannot be minimized

STRONG PLEA

Venereology and dermatology must not be combined in one unit. Today, they are not the same as they were in the past. Both have grown tremendously and are expanding continuously and invariably need a different approach. To combine them in one unit is to turn the clock back by fifty years, to an age when increasing enlightenment is at last setting venereology on a par with any other medical speciality and a venereal patient on a par with any sick person. In spite of these facts, a sad tendency is still noticed in some quarters to return to the days of the past, which is found often to result in the inefficient treatment of venereal patients.

Two separate chairs and departments for these two branches of medicine need to be instituted in every teaching medical college and its attached hospital. Every general hospital ought to have a separate department of venereology with adequate staff, equipment and accommodation. This is the only way to provide specialized medical services to venereal patients and to ensure proper training in venereology for medical students. Experience of the past years has amply proved that venereal patients, their work and training of medical students are totally neglected generally in a hospital where there is a combined department for the skin and V.D. The way patients are dealt with herein is nothing sort of quackery. The reliable diagnosis, correct treatment, education of the patient with regard to his disease, contact-tracing, case holding, follow-up tests and record keeping to ensure complete and permanent cure etc are rarely done even in the so called teaching institutions. This is very shocking but absolutely true. To remedy the situation, it is all the more important to recognize venereology as an important branch of medicine and to institute a post graduate degree or diploma in venereology. In consonance with this basic principle, Universities of Madras and Delhi have already instituted a separate post graduate qualification in venereology. For the sake of national interest and uniformity, it is necessary to follow the same policy everywhere. The need to remove this somewhat glaring inconsistency in medical education does not seem to have received the attention it deserves. This is an age of specialization and students of medicine ought to get all facilities to equip themselves properly in venereology. Equally important is that venereal patients get specialized medical services, for skilled medical services are not only useless but also dangerous from the point of patients’ health and the public health as well. There is a strong case for expediting decisions on venereal policy. There is such a stalemate in our medical education and services today that bold decision alone can pay rich dividends.

URGENT NEEDS

It is necessary to provide free and adequate diagnostic and treatment facilities for venereal patients. At present, there are very few diagnostic-cum-treatment centres for venereal patients even in cities like Bombay and in the country as a whole, though the incidence of V.D. is very high. It is a fact that authorities in charge of many private, public and E.S.I.S. hospitals are generally very reluctant to appoint venereologists and to provide specialized medical services to venereal patients in their establishments, though this can be done easily and without any additional burden. This crass apathy on their part must end, sooner the better. A venereologist must constitute a part of the comprehensive team of specialists for each and every hospital. Otherwise the preservation of this speciality will be in danger. The National Health Service in U.K. invariably includes venereologists in addition to dermatologists in its medical staffing but we shun for no valid reason to do so for E.S.I.S., C.H.S., and general hospitals. A chain of laboratories such as central, district town and field laboratory must be provided all over the country. This is a very important step for an early and accurate diagnosis of V.D. and its permanent cure can be established. Clinical or naked eye impressions or assumptions are totally untrustworthy and often dangerous in the management of V.D. The generalists in private medical practice who are the back- bone of health services, usually lack in this facility and are in great want of laboratory aids. With the help of these laboratories, they can effectively share responsibilities in the control of V.D. and help to reduce the load of medical work on the public hospitals. It is the duty of the government and the civic authorities to cater to these urgent needs. To allow these patients to go uncared for and untreated creates a danger to society and the public in general. This fact needs to be realized very clearly by the people in authority.

EDUCATION AND LEGISLATION

Education of the public with regard to these diseases by means of press, radio, cinema, talks and posters needs to be undertaken right earnestly. It is a very useful weapon against the spread of these diseases. At present there is a good deal of ignorance, superstition, secrecy and prejudice on the part of the general public. But the common experience is the flat refusal for the purpose, you go anywhere. Isn’t this strange when we can talk freely about birth control and family planning? Some type of legislation needs to be enacted making the blood test for syphilis necessary as a part of the routine physical examination or check-up before employment, marriage and in pregnant women. Deliberate transmission to others has to be made a crime. Treatment of infectious cases and of defaulters in treatment must be made compulsory.

Every state must have an institute of venereology where medical and paramedical personnel can be trained in the specialized work. The growing number of clinics would need trained personnel and the institute can be relied on to prepare and supply them. In the year 1958, the then Government of the State announced its decision and sanctioned the establishment of a training centre in venereology at J.J.Hospital, Bombay. Nearly ten years have passed and one does not know when it will come into existence and start functioning. Does this show- sincerity of purpose or respect for word? It will be no exaggeration to say that more damage is done to the cause of public health by our sustained indifference to the interests of venereal patients. The havoc is grimmer and more distressing because of the haphazard policy that is adopted by the Government and some universities in regard to venereology. The need for national orientation in the development of venereal policy is urgent. The crisis of health services needs an urgent attention. It should help to alert the public to the urgent requirements for more active planning and priority setting for health and medical services. It is the right of the public to demand the provision of specialized medical services for venereal patients, elimination of V.D. and protection against the risk of health. In the socialist pattern of our society, the Union Government has rightly pledged to the ideal goal of providing specialised medical services not only in the cities but also in district and town levels. How can this objective be achieved when they refuse to appoint venereologists on the teaching staff of medical colleges and on the panel of specialists for most of the general hospitals? It would be very unfortunate if advances in medicine and chemotherapy bred complacency in dealing with venereal patients or the fallacy that venereologists are no longer required. The pattern of medical services has throughout history been one of constant and continuous change. The existing pattern of diseases in the country and the health needs of the people at present and in the foreseeable future ought to form the background for training various categories of health personnel. The concept of comprehensive health services has come to stay even as a remote ideal and one has to develop resources in a planned manner and on a phased basis to coincide with our varying and growing needs. The increasing complexity of modern medicine demands a team work of many categories of health workers and special attention must be given to the training of venereologists and paramedical workers, who would be needed to man the growing number of clinics in the country. Medical education for both the under and post graduates is of paramount importance in the development of comprehensive health services. There is an urgent need for improved education in venereology for medical students. It is incredible that medical students still receive no teaching or instructions about V.D. throughout the whole course of their training. An adequate and proper training of the under- graduates in the principles of diagnosis and treatment of V.D. and its allied problems and the recognized system of training for intending specialists in V.D. are still to be provided. There is a real danger that trainees in venereology will cease to come forward, as it is found today, unless a policy for the preservation of this speciality is adopted as soon as possible. It is no wonder that in spite of growing number of new medical colleges, we could not have similar increase in the number of venereologists in the country. The reasons are obvious- reluctance to appoint them in new medical colleges and hospitals, lack encouragement, incentive and official apathy. If we sincerely desire to fulfill the ideal goal of specialised medical services, and the government has already committed to it, there is no way but to recognize venereology as an important speciality, establish a separate venereal clinic at every hospital and appoint a qualified venereologist to offer specialised medical services to venereal patients. So long this basic and urgent need is not conceded, there is no hope of providing the right type of medical services to venereal patients, improving standards of medical education and training in venereology for medical students and intending specialists in venereology.

All that we have done so far is to shut our eyes, ignore the presence of this problem, and learn to live with this scourge. Such callousness, crass apathy and total disregard for public health and welfare would be very rare to find anywhere.