WHAT CONTRIBUTES TO THE RISE IN V.D.?
Major M.P. Vora
The Bombay Civic Journal
Vol. XIX, No. 11 of January 1973; Pages 18-21
The recent world-wide increase in the incidence of venereal diseases has once again drawn our attention to the various causes that contribute to their spread. The rise in the rate of incidence and prevalence of V.D. has been universal and has assumed alarming proportions in many countries including India. This tread is equally applicable to countries like the U.S.A., France, United Kingdom, Sweden and Italy where well developed health services exist. During the period from 1954 to 1964, there was 75 per cent increase in Britain. In the U.S.A., cases of infectious syphilis rose from 6,251 in 1957 to23, 250 in 1965 i.e. (272% rise) and there was 8.9 per cent rise in the incidence of gonorrhoea during 1970 to 1971. Reliable statistical information about V.D. is lacking in our country. However, it is estimated that more than 20 million persons are affected every year and 13 % among them are teenagers. The prevalence rate of syphilis alone, as could be inferred from serologic positivity rate, should be in the vicinity of 10% of the population as against 0.025% in the U.K.
The factors which are responsible for this state are many and varied. Some of them are known for criteria, while others are new and were unthought-of of in the past. It would be, therefore, befitting to study and analyse social, behavioural, medical and ecological influences which are responsible for this unsatisfactory situation.
Emergence of resistant strains of germs that cause venereal diseases: Some of the organisms that cause V. D. have recently shown an increasing resistance to penicillin and other antibiotics. This is the result of indiscriminate use of antibiotics. Many patients with syphilis or gonorrhoea are inadequately treated, through the use of inappropriate antibiotics or appropriate antibiotics in inappropriate doses. This has been particularly true of the Neisserian gonococcus, the germ causing gonorrhoea. The importance of resistance to antibiotics is that the treatment may remove the signs and symptoms of the disease but the patient may not be “cured”. He or she may remain infectious and capable of spreading the disease to others, unless repeated physical examination and laboratory tests are carried over a certain period of time to ascertain and confirm “cure”. A physician who wishes for the well-being of his patient ought to be particular about these tests.
The presence of the great reservoir of infection: Another important factor in the spread of V. D. is the great reservoir of infection in most women and a few men who have no symptoms of disease. It is not generally recognised and widely known that a large proportion of women infected with venereal disease have no symptoms. This also true to some extent in men. If they are promiscuous, they are sure to spread the infection to many others. This is very true of the gonorrhoea, viral infections of the genital tract and syphilis. The only method of bringing these persons to a doctor for investigation and treatment is by ‘contact-tracing’ in cases of all newly infected persons. But many persons are unable to trace their infecting partners or unwilling to disclose their identities. Further, it is seldom easy for the doctor to persuade a bitter and disillusioned patient to seek out the source of his or her infection and persuade him or her to attend a doctor or a clinic. For these reasons, many women and a few men with asymptomatic infections are not detected and treated for long periods of time. They form one of the most source of the persistent epidemic of venereal diseases. Recognition and elimination of the source of infection of an established case is of prime importance in the successful control of V.D., and where the fastest and greatest progress in the shortest time is desires, the most effective force and efforts must be concentrated at this point. Persons with recently acquired infections, if handled skillfully and tactfully, are potentially valuable because they can supply details of the source and contacts of infection. However, this important point is generally neglected in most of our clinics. Screening of a person for venereal disease should form a part of any general examination of a patient.
A change in the pattern of sexual behaviour: A new factor in the rising incidence of V.D. is the increasing number of homosexual activity is probably more dangerous than promiscuous heterosexual activity. Promiscuous homosexual activity is probably more dangerous than promiscuous heterosexual activity. Homosexuals are generally unaware of their diseases. Infection of the passive agent may give rise to few symptoms or none, thus delaying early diagnosis and treatment. Undiagnosed infection carries a great risk of the spread of infection. Lesions at unusual sites are often missed even by an average physician. It is not always realised that venereal diseases are common among homosexuals and they do not seek medical advice until the advanced stage of the disease appears. Reports from U.S.A., U.K. and France indicate that infectious syphilis and gonorrhoea are found with increasing frequency in homosexuals. Hence our pattern of interrogation and examination of cases must undergo a change to spot out early these cases.
The modern treatment of V. D. has turned out to be a curse in disguise: The present safe, speedy and effective therapy for V.D. is not an unmixed blessing and has become a source of increase in the incidence of venereal diseases. Repeated re-infection often occurs now-a -days in the same patient in comparatively short periods of time. This has been attributed to the simplicity and speed of modern treatment, which removes the signs and symptoms of the disease quite rapidly. This permits individuals to run repeated risks of further infection within a short time of starting treatment. It is now possible to acquire and be treated for several venereal infections during the same short period of time; formerly such a thing was unthinkable and impossible. To treat a single infection then used to take months. The fear of venereal diseases, which exerted as a deterent against promiscuity in the past, does not exist today. Persons run repeated risks at short intervals thus increasing the incidence of V.D.
Radical change in the outlook of sexual behaviour: Ideas on morality are fast changing, the old values are disintegrating and the old good ways ar4e no longer honoured. The moral order is undergoing regeneration as well as decay. Social relations and free mixing between the two opposite sexes and tolerance of fornication are increasingly evident. This trend towards greater sexual freedom is probably universal. The evidence from a number of countries suggests that there has been a radical change in the outlook towards sexual behaviour in the recent years. There has been an increase in sexual promiscuity; both the pre-marital and the extra-marital sexual intercourse are more frequent and widespread amongst the general public than they were in the past. In human history, sexual irregularity has been far older and stronger than sexual morality, despite rigorous taboos. What is really noticeable is that the area of irregularity is spreading out into new spheres. This has naturally resulted in the increase in the incidence of the V.D. Permissive society has come to stay and free love is replacing the old hypocritical double standards of morals. But seeds of danger are implicit in this trend. Venereal disease is a price one has to pay for indiscriminate indulgence in sex.
Prostitution: By definition a prostitute is a person who habitually offers herself or himself to different individuals for sexual purposes in return for payment in one form or other. The role of prostitution in the spread of V.D. has been a subject of frequent discussion and has provoked divergent views. Economic factors, illiteracy, social disorganization, mobility, urbanization and industrialization have their repercussions. The part played by prostitution in recrudescence of V.D. is complex one and has been studied in some length and depth in many advanced countries like the U.S.A., U.K., and France. Their findings are very interesting and illuminating. From these investigations, it seems reasonable to conclude that sexual intercourse with a casual acquaintance is the commonest method, in which risks of acquiring venereal diseases occur and indeed, it is the most frequent method by which venereal diseases spread today. The Prostitute continues to play a significant part in the spread of V.D. specially amongst tourists, travelers, soldiers, sailors and in many Asian countries; but her place is being taken increasingly by promiscuous amateurs, who are often asymptomatic carriers of infectious diseases. In support of this view, many other workers have shown that a prostitute, who once occupied a key position in the spread of V.D., has now receded in the background and that the promiscuous non-professional pickups and amateurs have assumed the important role in modern times. The prostitute only accounts for about one quarter to one third of all venereal infections at present. In India, about 32% persons suffering from V.D. acquire their infections from prostitutes.
Because of the rise in the incidence of V.D., many people suggest abolition of prostitution and brothels, licensing of prostitutes and their homes and segregation of areas in the cities. Complete abolition or elimination of illicit sexual activities would not be feasible. The hard core of sexual activity remains fairly constant from age to age. Only its area is spread out into new social spheres i.e. friends and acquaintances. Adequate and repeated medical examinations of prostitutes to exclude venereal infections are not likely to be achieved or practicable. Regular examinations of prostitutes are inefficient and ineffective, they lead to corruption and lower professional and ethical standards amongst medical men, create a false sense of confidence and security among the clientele and increase clandestine prostitution. It is true that infections in prostitutes can be reduced by regular intervals medical examination and treatment of the infected at regular intervals. But these steps have been found to be ineffective and unreliable as a means of controlling the spread of venereal diseases. They touch only a very small fraction of the problem and encourage clandestine prostitution by girls, who wish to avoid regular check-ups. For these reasons, there is amongst an universal agreement amongst venereologists, who have studied the problem, that the state registered prostitution is not the answer to the problem of increasing incidence of venereal diseases.
Recent International Congress on Prostitution held in New Delhi, in sharp contrast to the traditional attitude, has recognised the fact that modern society is finding a solution to an evil of prostitution that has flourished despite generations of pseudo-moral preaching. The congress was frank enough to look forward to disappearance of prostitution with permissive society coming to stay and free love replacing the old hypocritical double standards of morals. Elimination of economic incentives for prostitution is the only effective way to eliminate the evil, it said. But can permissiveness in sex and free love be free from dangers of V.D.? This aspect cannot be overlooked. It means that prostitution may go away but V.D. would continue to flourish. Fear of V.D. does not seem to be effective for the permissive society.
Movement of the Population: It is one of the factors concerned in the spread of V.D. The large scale movement of the population from one area to another has an important bearing on the present situation. The increasing mobility of the people, the movement of the workers from their homes to new places of employment, growing use of air and surface transport and migration of large numbers of people from the mofussal to the urban areas with large scale industrialization, war, famine, earthquakes etc. have their share in the spread of venereal diseases. We are in the jet age which makes it possible for one to fly within a week to a dozen places to make love and to make speedy transfer of infection from one place to another.
Freely available and effective contraceptives have removed the fear of pregnancy and encouraged casual approach to sex. The increased incidence of V.D. is evident as a side-effect of the present policy to popularize the pill and the loop, which have been partly responsible for the promotion and increase in pre-marital, extra-marital and promiscuous sex relations.
Unjustifiable indifference and complacency on the part of medical men and health authorities:- There has been a persistant, false and pernicious feeling among the general public and medical men, who are actually not connected with the practice of venereology, that these diseases are dying or dead with the advent of new drugs. This has naturally resulted in laxity and slackening in efforts. Far from dying these diseases are very much with us, giving rise to resurgence of venereal diseases. It must be clearly understood that new drugs alone could not help to control these diseases. A drop in the incidence must no t result in a corresponding drop in the interest and efforts. For, these diseases have a unique ability to flourish and spread. To control them, a sustained and continuous effort must be put in.
Absence of any worthwhile programme for the control of V.D. at the State, Central and International level: - The modern medical science and epidemiology have provided us with efficient told for the control of V.D. and mitigation of sufferings of the population. It is the statutory obligation of the health authorities everywhere to implement the recommendations of the experts. Application of uniform technics, procedures, programmes and co-operation at the State, Centre and International level are necessary.
FACTORS CONTRIBUTING TO RISE OF V.D.
The reasons for the increase in the incidence of V.D. are complex and involve medical, behavioural, social and ecological considerations. The most important factors which have contributed to this rise are: - the emergence of resistant strains of organisms, the large reservoir of asymptomatic and undiagnosed infection in some men and a large number of women, the change in the pattern of sexual behaviour, the simplicity and speed of modern treatment for V.D., the generalised and wide-spread promiscuity amongst the general population, emergence of permissiveness and free love and total indifference and complacency on the part of the health authorities. Evidence suggests that prostitution continues to play a significant role but its importance is almost certainly declining. The principal spread is through promiscuous casual contacts and the frequency of this type of sexual experience seems to be increasing in all sections of society. The reservoir of infection amongst women with no symptoms is particularly important in this group and because of the casual nature of many of the relationships, contact-tracing and examination and treatment of those who are infected with V.D. are extremely difficult.
CONTROL OF V.D. POSSIBLE
Control of venereal diseases will only be possible when (a) the public has been fully educated about the dangers of contracting sexually transmitted diseases, (b) an adequate medical education in venereology is imparted to medical students, (c) medical advice and suitable facilities for diagnosis and treatment are made freely available everywhere. This means recognition of venereology as a speciality, appointment of venereologists in hospitals and establishment of venereal clinics, properly staffed and equipped, to offer specialised medical services to venereal patients. But nothing has been set right so far and nothing would be set right as long as the bureaucratic obduracy, intransigence and stupidity continues.
Medical educationists and health authorities ought to shake off their indifference and show increasing interest in the problem of venereal diseases. They must pay greater attention to medical education and the practice of venereology. They will do well to study the report of the National Commission on V.D. sponsored in 1971 by the Department of Health, Education and Welfare in the U.S. A. Its findings have an equal application in this country. The time has come for a bold and realistic approach to the problem. It is hoped that proper methods of diagnosis and treatment will be applied to all those who have run the risk of contracting or acquiring venereal infection and that the possibility of such infection will be constantly in the minds of physicians while dealing with their patients. It is inexcusable for a modern physician to be unable to recognise early, treat properly and contain the spread of V.D. through proper public health measures.