PORTRAIT ON VENEREOLOGY
By Dr. M. P. Vora
The Bombay Civic Journal of May 1973
NEED FOR ORGANISED MEASURES
No subject is so much permeated with prejudice and ignorance as are venereal diseases, which constitute an urgent and serious health problem. Their rates of incidence and prevalence are alarmingly high in the country. More than 20 million people are infected with V.D. every year according to the Union Deputy Health Minister Mr. A.K. Kisku. This figure constitutes only a fraction of the total numbers. For every case that comes to light, there are at least 20 or more undetected cases among the public. Such a high rate of incidence combined with the peculiar conditions that prevail in the country, makes V.D. the gravest public health hazard. Nevertheless, our health authorities are reluctant to call them as pandemic or highly epidemic diseases. Moreover, the havoc caused by them is considered, unworthy of attention. The number of infected with V.D. swells ever increasingly as there are no organized measures to control them. There is sufficient justification to treat them as a national health problem of great magnitude. However, no one seems to be disturbed. Even the recent warning by the World Health Organisation, “The world is today in the grip of a virtual epidemic of V.D. and the seriousness of the problem is not in doubt”, does not dispel our “lassez faire” attitude. There is always a compassion and concern for the leper or the consumptive but condemnation for the venereal patient. No wonder that these diseases make no appeal for help, care or charity. Few can hope to get funds for the projects.
Medical services for these diseases are very scanty, variable and generally very unsatisfactory throughout the country. In most of the medical institutions and hospitals, venereology does not find a place in the list of medical specialties, and is generally considered as a part of dermatology. This has led to dismal deterioration in the standards of 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. The way venereal patients are dealt with, at present, is nothing sort of quackery. 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 appropriate laboratory tests, proper and adequate treatment, contact-tracing, case-holding, education of the patient with regard to his or her disease, record keeping and tests of cure are rarely performed even in the so called teaching medical institutions. This is shocking but absolutely true, its grave impact on the health of the sick, the community, and the national economy is totally ignored.
NEED FOR MORE LABORATORIES
Assuming that one fully equipped and staffed V.D. Clinic is necessary for a lac of population, we would need roughly, 50 clinics in the city of Bombay to cope with the local needs and some 5000 clinics to meet the present requirements of the population in the country. As per the Government’s announcement (The Times Of India, December 19, 1972), 142 clinics were established in India, during the first three Five Year Plans and 50 clinics are proposed to be startedduring the fourth Five Year Plan, of these 30 have already been established. However, there was no reference to the provision of laboratories, which play an important role in the practice of venereology. When will be the target 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 staff, equipment, accommodation, drugs, laboratories, technicians etc. Venereal disease clinics as a rule do not see better days anywhere. Although they are set up at hospitals, they somehow fail to remain in the hospital being crippled without any amenities, funds, staff, space etc. In general, there is no provision for inpatient care, thereby showing neglect of clinical instructions and demonstration of medical students. If one was to compare V.D. clinic with any other department of the hospital, the most glaring and contrasting picture would emerge. Long delays, humiliation, lack of privacy, inefficient medical service, difficulties in cross-references, paucity of staff, technologists, social workers, laboratory equipment and technicians etc. are common in most clinics, which work for a few hours only in a day or on alternate days. It is necessary to extend the hours of V.D. clinics by introducing additional evening sessions to reduce the morbidity rate. From what has been started, one can easily imagine the practical utility of most of these clinics.
FACILITIES FOR SPECIALISED MEDICAL TREATMENT
Even in a place like Bombay, which can boast of many fine hospitals, nearly 90% of the venereal patients have to go without proper medical care, leave aside towns and villages where elementary medical services are rarely available. The tall talk of providing specialized medical services for every one in the country amounts to an insult to the venereal patient, when most of the hospitals are without venereologists and venereal departments. The policy of merely adding to the number of clinics without specialists, technicians, equipment, teaching curricular and environment can only lead to increasing wastage of precious resources. The process of consolidation and improvement of the quality and content of the existing clinics along with gradual increase in their number is very urgent. But few seem to bother. As a result, few medical students can hope to get them properly acquainted, during their studies, with the basic knowledge and facts in the diagnosis, treatment, and control of V.D. the World’s third most prevalent infectious disease. The reasons for all these ills are our out-dated and irrelevant concept of “dermato-venereologist” patronized by health authorities and medical educationalists in the country. Dermato-venereologists often lack keenness and interest in venereology and venereal 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. it is common experience that they utilize most of the hospital facilities, amenities, staff and funds for dermatological work. To them retention of their own hold on the subject means everything. The effect of this concept is that venereology gets relegated to the background and venereal work suffers a total eclipse. In support of this observation, many instances- both national and foreign- can be citied. But we seem to learn nothing from them.
NEED FOR RESEARCH
Venereology is intimately connected with public health and other branches of medicine and is inseparable from them. However, venereal diseases rarely constitute a part of programmes either of public health or any other branch of medicine or interdisciplinary seminars. In venereology, a special emphasis is placed on every case to find out its source of infection and other contacts so as to check the spread of V.D. The department of social and preventive medicine should offer and extend facilities and special studies relating to epidemiology, and social and preventive aspects of V.D. Despite continued threat and epidemic outbreak of V.D. in the country, venereal diseases have miserably failed to secure recognition for propaganda and general awareness. Authorities in charge of mass communication media are reluctant to meet their obligations. As the result, vast masses still remain totally ignorant and uninformed about V.D. It is very unfortunate that they do not realize the importance of public education in checking the spread of these diseases and the fact that the future sanity and sanctity of mankind lies in their hands.
PROPER EDUCATION AND TRAINING
A university chair in venereology is essential and one sincerely hopes that it will not be long delayed. This will offer true guidance and inspiration and the subject will receive greater and better attention than at present. Emphasis will be on scientific diagnosis, proper treatment and efforts to control V.D. To trace and examine potentially infectious contacts so as to reduce the morbidity rate is quite scientific justification for making this a separate specialty. Those who advocate or persist in the concept of ‘dermatovenereology’ which has totally failed to show tangible results during the last thirty years and has induced rank confusions in matters of education and training in venereology must look more deeply into the matter to realize the mistake.In this connection, the report of the National Commission on V.D. (1971) by the department of Health, Education and Welfare in the U.S.A. should be of great interest. The conditions in our country as far as the standards of teaching and training in venereology for medical students are concerned; do not differ very much from those in the U.S.A. Total lack of familiarity with V.D. and under-estimation of its importance are common in medical profession. Having been struck by a similar idea, the writer had suggested, as far back as November 1967, to the President, the Medical Council of India, to appoint a special committee to study and report on the problem of medical education, training and medical services in venereology. However, it failed to evoke any response beyond an acknowledgement. This was the fate of timely and appropriate suggestion.
ADEQUATE STEPS TO CURB THE GROWTH
Venereal disease in one form or other is common in the practice of almost every physician. Its manifestations may be obvious or hidden. It may occur in men, women and children of different ages. Its symptoms may be so diverse as to cover the entire range of medicine; many patients find themselves admitted into medical, surgical, gynecological, ophthalmic, skin, ear-nose-throat, cardio-vascular or neurological wards for the treatment of complaints, which originate as a result of uncured venereal infection. Is it not obligatory for a modern physician to recognize these diseases in early stages, treat them properly and control their spread in the community, especially when the incidence of V.D. is very high? How can this inability be condoned or excused? Early and adequate treatment of V.D. can save many hospital beds and consequent sufferings and expenses. To achieve this goal, proper education and training in venereology is indispensable and indisputable. Respect for venereal diseases is in direct proportion to the amount of time spent in study and training in the subject. But this does not get the attention it deserves. Virtually there is no provision for this in most of the hospitals and colleges. Adequate teaching and training facilities for medical students, general practitioners and intending specialties in venereology must be provided in all teaching medical institutions. But most medical colleges and universities in India seem to be unconcerned and reluctant to introduce this progressive measure.
It is often told that there is a dearth of teachers, clinicians and trained personnel in venereology and that the subject do not attract young physicians. This may be partially true to some extent, but there are many valid and immediate reasons for this. They must be identified and quickly liquidated. It is a fact that local authorities have shown little interest in the repeated offers of “Shramadan” by the retired teachers and clinicians in venereology, resulting in a criminal waste of national human resources. When venereology does not exist in the list of medical specialties, how does a young physician 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, absence of guidance, associated stigma and prejudice, its underestimation or by some of the medical profession etc. are sufficient to kill instantaneously anybody’s enthusiasm for the speciality. No wonder there are but few recruits. If we desire to make some headway and create an interest in the subject, venereology must get due recognition and feel its importance in medical education, training and services. Appreciation of good work, grant of scholarships for the subject and distribution of awards for teachers, clinicians and writers in the speciality should act as a great incentive. So far, the writer is not aware of any instance of that nature. The unnatural and the uneasy link that is created between venereology and dermatology ought to end promptly. The Grant Medical College and its attached J.J.Hospital, Bombay, where venereology has been a separate speciality for over thirty years, can be legitimately proud of having induced young physicians to take up the subject and having turned out some fine teachers and clinicians in that subject. The same does not hold good in the case of most other medical colleges and their attached hospitals, where the subject has not been recognised as a separate speciality. Take the example of United Kingdom, where 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 disease service. The effects have been remarkable and applauded with praise. Because of enlightened and dynamic policy, the British treatment of venereology can be regarded as an ideal example to follow. Indeed it has done a pioneering work to resuscitate and rehabilitate the most neglected speciality in the world.
VENEREOLOGY AS SEPRATE SUBJECT
Dr. C. S. Nicol, famous British venereologist, who visited India in 1971, was frank enough to express his dissatisfaction with the Indian system of specializing jointly in venereology and dermatology and establishing a combined department for these in a hospital or medical college. He said “If India is to contain her present critical situation and prevent further increase in V.D., which will occur in the next decade; she must maintain venereology as a separate subject in the field of medicine for the under-graduate and post-graduate teaching at her universities and must establish institutes of venereology and laboratories in every state”. But this has failed to produce any effect on the idle minds of our medical educationalists and health authorities. The University of Bombay, Municipal Medical Colleges and hospitals, C.H.S. and E.S.I.S seem to be bent on pursuing their ill-conceived policy as far as venereology is concerned. Their obduracy and intransigence to accept the change for the better is queer despite the general consensus of opinion among deans of medical faculties of all universities and venereologists in India. Isn’t it the height of ridicule and stupidity that Medical Council of India, which is supposed to maintain high standards of teaching and training, should have approved once again, only in the last year, the policy of specializing jointly in dermatology and venereology, notwithstanding the fierce opposition? This dismal performance is entirely a result of mismanagement, vested interest, and apathy to learn. When will the Medical Council of India give up its irresponsible and irrelevant attitude towards V.D.?
URGENCY TO SOLVE THE PROBLEM ON NATIONAL LEVEL
In our country, venereologists are considered “outcasts” in the higher levels of national health, medical education, planning and management. This less salubrious attitude towards V.D. and venereology is to be found even within the medical profession as among the laity. Outside venereology, there are a few among the highest ranks of medical profession, who regard venereology as unworthy of special study, and many remain unaware of the diversity of its interest, complexities, wide horizon and involvement. There is need for urgency to give venereologists due status and position in spheres of national health, medical education and training. Will the authorities concerned think over the matter afresh and correct the inept situation, for which we have to pay dearly? It is high time venereologists are considered as a part and parcel of the medical profession and given due consideration. It would be a great mistake to reject lightly their most sensible plea for the recognition of the subject. On this very fact would depend progress and advance in the subject, its technology teaching, training of medicos and ultimate means of V.D. control in the country. It would be rank folly to persist in the policy that has failed to show worth while results during the last thirty years of its existence. Why it should not be an intimate concern of our city fathers, M.L.As and M.Ps to improve and preserve this speciality in the interest of humanity? Wouldn’t they like to take up this matter right earnestly as V.D. continues to be a grave and hidden menace of the ignorant and indifferent? Isn’t it the right of the public to demand protection against the risk to health? Is it legitimate to deny them this basic right?