V. D. – A NATIONAL PROBLEM
By Dr. M. P. Vora
Ref: The Illustrated Weekly of India
September 9, 1962, Pages 57, 59 & 69
Of all the social ills of man, the least confined, the least manifest, and the least likely ever to be static is venereal disease, which constitutes the most dangerous hazards to public health, with the heaviest impact on our national economy. In a country like India, where accurate statistics of most of the communicable diseases are lacking, it is not at all surprising that correct figures of the incidence of venereal disease are non-existent. However, some idea of the wide prevalence of this scourge can be obtained from the attendance at the V.D clinics, as also from serologic surveys in anti-natal clinics and among blood donors and mill-workers.
It is generally accepted that 5% to10% of the urban population is sero-positive to syphilis, while some 60% to 70% of V.D. patients are in the infectious stage. Further, a considerable number of patients escape recorded observation. And the rising incidence of latent syphilis, penicillin-resistant syndrome of gonorrhoea, and non-gonococcal urethritis, with the marked involvement of the younger age-group, certainly makes the picture very grave from the point of view of public health.
In the year 1920, the J.J.Hospital, Bombay, recorded that 18.7% of its indoor patients and 29.3% of its outdoor patients had evidence of V.D. in an active or quiescent form. At the Motlibai Petit and Cama Hospitals for women, 10% to 15% of the patients were sero-positive to syphilis. Among the two thousand yearly still-births in the city of Bombay, 18.5% were due to syphilis. Out of the 9,000 children that died annually in Bombay, 3,000 died of congenital syphilis. Of blind children, 30% of deaf children, 25% of mentally deficient children, 50% were the result of V.D.
In the year 1930, some 40,000 workers in 32 mills of Ahmedabad were put under observation and their cases were studied, 6% of them proving to be infected with syphilis and 8% with gonorrhoea. The consequent reduction in the man-power at the mills went up in some cases to 20%.
In 1933, while investigating the health aspects of village life in India, Sir John Megaw estimated that there were over 13 million cases of syphilis and gonorrhoea, of which 7.5 lakhs were treated in hospitals. This would give an average prevalence rate, at that time of 37.1 per 1,000 of the population. He also observed that for every 20 persons suffering either from syphilis or gonorrhoea, only one sought treatment in a hospital and the rest either received none or were treated by quacks or private practitioners. Hence, the real prevalence rate of the two principle diseases among the general population would have to be estimated at 20 times the hospital rate. He noted further that 60% to 62% of the patients who sought hospital treatment were in an infectious stage. Applying this ratio, he concluded that more than 1.5 million persons had V.D. in the most infectious form and were a source of danger to others.
In 1945, 300,000 patients with V.D. attended hospitals in Madras State giving an annual hospital attendance rate of 6 per thousand, the highest in the world. The annual hospital rate for the city of Madras was 20 per thousand- four times are provincial rate- according to Dr.R.V.Rajam.
In 1959-60, the Government of Maharashtra reported that 41,000 venereal patients were treated as out-patients and 665 as in-patients in the Government hospitals in the city of Bombay. Besides, the Bombay Municipal Health authorities recorded 1,000 patients at the Nair Hospital, 3,122 patients at the K.E.M. Hospital, and 19,470 patients at the Alexandra Clinic. Thus the total number of officially recorded V.D. patients for the city of Bombay came to 65,257 for the year. Applying Sir John Megaw’s observation that 1 in 20 V.D. patients seek hospital treatment, there must be over 1.3 million people suffering from V.D. out of the 4.2 million population of the city Bombay. What a staggering figure!
If we assume that 5% of the Indian population is suffering from syphilis, nearly 2 million will be affected with syphilis alone. And the prevalence of gonorrhoea often exceeds that of syphilis: hence another 2 million or more will be suffering from gonorrhoea. Four million out of 40 million, or 10% of the population, afflicted with these diseases is certainly shocking. But in Himachal Pradesh, Jammu and Kashmir and Kulu, 30% to 40% of people are found to be sero-positive to syphilis. These figures will convince any sane person that all is not well in our country as far as venereal diseases are concerned.
TRAIL OF DAMAGE
Venereal diseases are communicable and need to be treated as such. Every case of infectious syphilis or gonorrhoea is to be regarded as a matter of medical urgency, constituting an emergency which could lead to an epidemic. It is not right to treat these cases differently from those of other communicable diseases. They affect both the guilty and the innocent. Syphilis is a great killer of humanity. It can cause blindness, deafness, crippling disabilities and pre-mature death. Of admissions for disorders of the nervous systems, 50% and of admissions for diseases of cardiovascular system, 15% in the hospitals are due to syphilis. Gonorrhoea is more prevalent than syphilis and causes ill-health and sterility in both sexes. Blindness in the new-born is often due to this disease. Though the immediate mortality resulting from venereal diseases is not high, their gravity from the point of chronic ill-health, incapacitation and economic loss cannot be overrated. The damage done by them is enormous and often irreparable.
Our V.I.P.s go about the country presiding over, or inaugurating, medical and health conferences and exhibitions, but they never refer to the problem of V.D. in India. They are more concern to talk about tuberculosis, cancer, malaria, and leprosy. But if one compares these diseases with syphilis and gonorrhoea, it appears from hospital returns that syphilis alone is five times more prevalent than tuberculosis and six times more so than leprosy. Among chronic communicable diseases, V.D. will easily take second place next to malaria in point of prevalence.
Though venereal diseases constitute a major public health problem, they are often relegated to a position of no importance. In no other branch of medicine does the quack, both within and without the profession, find so fertile and profitable a field of exploitation. The curing of V.D. is supposed to be so simple that anybody can begin to practice it with impunity. And the attitude of an average qualified medical man, not associated with the actual practice of venereology, towards these diseases, is mainly of the hit-or-miss therapeutic type. Further, the effectiveness of modern drugs in the treatment of V.D. has only helped to strengthen the causal approach to problems connected with venereal diseases. Accurate diagnosis, contact-tracing, case-holding, proper record-keeping, clinical study, follow-up and the test of cures are never thought of or are considered of minor importance to therapy.
ROLE OF PROMISCUITY
The problem of V.D. is related to those of prostitution and sexual promiscuity. The mere enactment of laws against prostitution is of little value. The prostitution as a spreader of venereal disease has receded into the background, while the amateur-the call-girl or the pick-up today takes a leading part in the spread of V.D. Sexual promiscuity need not, as such, be a factor in the spread of V.D. A group could in principle remain sexually promiscuous indefinitely without V.D. infection, if it had never been contaminated from outside. But in actuality, the chance of any promiscuous group’s protecting itself from V.D. is remote. From the point of view of public health, we have to concern ourselves more with the medical side of promiscuity than with its moral aspects, which vary according to the time and place. It is profitless to dwell too much on venery and not enough on its associated diseases.
The entire institution of marriage appears to be afflicted by greater stresses and strains today than ever before, forcing one to revise one’s traditional idea of chastity. Recent changes in the public attitude towards sex and sexual behaviour are also creating an increasingly favorable environment for the spread of venereal diseases. Today’s increase in V.D. among younger people is related to other symptoms of social maladjustment, which include increasingly casual sex-relationships in large sectors of population, married, unmarried and adolescent. Urbanization and industrialization, which have received so much impetus during the last decade or so, carry with them a grave risk of the progressive venerealisation of the entire population, unless proper steps are taken without delay to control the spread of these diseases.
A careful survey of the present situation makes one disheartened at the sorry state of affairs in the country. The authorities have neither a clear cut policy in regard to venereal diseases nor well-planned and organized measures to tackle their control on a 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. No matter what venereologists suggest or WHO experts advise, the 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, which carries us nowhere near our desired objective.
What a few clinics we have are in urban areas. No facility whatsoever exists in the districts or towns and villages. Most of the existing clinics offer an uncongenial atmosphere and are working at a grave disadvantage, for want of proper and suitable accommodation and equipment and adequate staff. Proper methods of diagnosis, case-tracing, case-holding, record-keeping, tests of cure and surveillance- the most important of venereal diseases- are generally neglected. In most clinics, no attempt is made at accurate diagnosis by means of modern scientific methods, or at contact investigation and bringing under treatment the source of infection.
NEEDED: A DIRECTORATE
Besides V.D. clinics receive step-motherly treatment from hospital authorities, who are generally ignorant of, or unsympathetic to the needs of a clinic. Very often one finds a member of the staff trained for a specialized job suddenly transferred to another department, without either the knowledge or the 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 and satisfactorily, it is essential that they should be under the direct control of a 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 in the present set-up, are unavoidable.
As things now stand in medical and public health administration, venereal diseases come under the Surgeon- General of a State. The venereologists have been unanimously emphatic that this is a very unsatisfactory and anomalous situation, which needs to be immediately rectified. 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 authority, the Directorate of Venereology, and bring all problems connected with V.D. under its control. And the State Government, must set up a separate division for venereal- disease control as part of the State and Central Health Organization, on the lines adopted by the Army during World War II Under such a central authority efforts at the control of V.D. can be adequately coordinated at the State and central levels, without which it will never be possible to adopt coherent measures and enforce these throughout the country.
The introduction of uniform methods of diagnosis, treatment and record-keeping, the lying down of minimum criteria in regard to the staff, equipment and accommodation in a clinic; the organization of training for specialized personnel; the serologic survey of selected groups of people; the collection of vital statistics; the direction of efforts in relation to established needs; the preparation and adoption of standard forms for the reporting of new cases; the obtainment of enabling legislation, rendering it, for instance, obligatory to report a new case, making treatment compulsory and enforcing ante-natal and pre-marital blood tests; the starting of mobile clinics for the rural population scattered in the villages; the posting of personnel; the supervision of the Division’s institutions; the yearly assessment of achievements; the initiation of research, are some of the functions which would belong to the central Venereal division.
To encourage the planned and organized growth of venereal institutions and to ensure their smooth running, a Directorate is of the first importance.
Now let us see what are the basic needs of a good venereal clinic, as repeatedly stressed by venereologists. If the clinics are to become efficient and popular, these basic needs must be fulfilled.
A venereal-disease out-patient department must invariably be located in and be a part of the ordinary out-patient department of a general hospital. It must not be separated or distinguished from it and it must go under some such suitable name as “social disease”, which will avoid the stigma generally attached to V.D. Among other obvious advantages, this saves the inconvenience to the sick of going from one place to another.
When planning some new medical activity, the need for a good venereal clinic is quite commonly forgotten. It is urgent that we examine the things that have gone wrong and decide how to put them right. Architects alone cannot produce good buildings for hospitals. These are constructed after a long and painstaking analysis of the activities to be pursued within their walls. They have to be carefully planned in accordance with their different functions. A hospital, like a factory, must be designed as a whole to enable many different activities to be carried on in it with the greatest possible efficiency, convenience and economy. In shaping their complex operation, the doctors who are to work in them can give much useful guidance. They can get together; formulate their programmes of medical requirements, procedures, staff, space and equipment, and these desiderata can be fitted into the architect’s plans. It is to be hoped that the authorities concerned will take note of these facts.
Venereology and dermatology are not normally to be combined in one unit. Two separate chairs for these need to be instituted in every teaching medical college. With the continuous expanding of medical knowledge in the domains of venereology and dermatology, and on account of the different approaches essential to each specialty, they must, as a working rule, be separated. This, by itself, will do much to maintain high standards of efficiency. Unhappily, however, this desideratum has been overlooked in the new medical colleges started recently, and many colleges and large hospitals in the country continue to have a combined department for these two specialties.
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 most. It is easy to understand a single specialist, whatever his likes and inclinations, cannot but do less than justice to these two specialties, particularly so when the findings of both are rapidly increasing in volume. Aware of the problem of V.D. in the armed forces, the administration in India, as also in the U.K. and the U.S.A. created, during World War II, a separate venereal division of their medical services, and the wisdom of this policy has been proved and confirmed by the subsequent results. It is necessary now, correspondingly, to create a separate venereal division or department in every general hospital.
There is no place in the contemporary scene for a hush-hush policy regarding venereal diseases. It is not surprising that Dr.Jiban.R.Dhar, the West Bengal Health Minister, was forced to urge the authorities to accept the difference between venereology and dermatology at the All-India Dermatologists Conference held in Calcutta recently. But when will our public authorities implement this suggestion in actual practice? Are not the patients of both entitled to have the benefit of highly specialized care?
A venereal clinic must have adequate and suitable space to ensure the privacy and separation of the two sexes and to carry out its different functions with the utmost convenience, economy and efficiency. Separate waiting rooms are absolutely required for males and females.
A venereal clinic must have a well-equipped laboratory, where the essential diagnostic procedures can be carried out on the spot and without delay, under the supervision of the venereologists. Most clinics lack the essential facility. Laboratory examination for accurate diagnosis of V.D. is an obligatory procedure before specific treatment is instituted and the important work of contact investigation can be undertaken. In venereal diseases, three procedures are a routine necessity: (1) the dark field examination for Trypanosoma pallidum. (2) A microscopic examination of smears for the detection of gonococci. And (3) the serologic test for syphilis. In every venereal clinic, these laboratory procedures are indispensable and the necessary equipment and technical personnel to carry them out must be supplied. In a clinic attached to a teaching hospital, the laboratory set-up needs to be more elaborate, for the purposes of training and research.
A venereal clinic requires at least two social workers, one male and one female, to carry out the work of tracing the contacts of an established case and to keep track of cases when these default, as often happens, either in the treatment or the follow-up tests. Tracing the original source of infection and bringing it under treatment is essential duty of a clinic. In the campaign against V.D. the important role of a social worker is not well recognized. He or she interviews the patients, acts as a liaison between him or her and the contact, and induces the last to take a check-up and treatment, if found necessary. The requisite training and sympathetic attitude on the worker’s side are extremely useful. The investigation of the contacts of an established case of V.D. is now well-recognized practice all over the world and cannot be neglected. How many clinics in this country have such a facility? Most of them have no social worker at all.
A venereal clinic must maintain standard records for each patient. For this purpose a trained clerk and necessary books are required items. Without proper records, the follow-up of cases needed to declare these cured is impossible. How many clinics can boast of regular and proper records of its patients? Most have none.
HOURS OF OPENING
A venereal clinic has to be open both in the morning and in the evening, so that the patients can attend whenever he finds it convenient. No patient should have to spend more than half an hour, either for consultation or for treatment, at each visit. At present a patient desirous of taking hospital treatment has to waste the whole day and lose his daily wages.
A venereal clinic must maintain a prophylactic centre open day and night. Prevention should be order of the day in the sphere of venereology. It has still its place of importance, notwithstanding the modern methods of treatment. The education of public in respect of V.D. prevention has a definite value and should be freely available.
A venereal clinic requires an adequate staff and technical personnel. It needs to be in the 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 the provision of suitable substitutes to carry on regular work. General practitioners who undertake to treat V.D. should be able to get free diagnostic facilities and consultant’s advice at such clinics. The following staff can cope with an out-patient clinic having 20 to 30 new cases per day:
One recognized specialist; two part-time medical officers; two laboratory technicians, one senior and one junior; two male dressers; two nurses, one senior and one junior; two social workers, one male and one female; two clerks, one senior and one junior; two sweepers, one male and one female; one compounder; two peons; and one ayah. The average monthly salary for the personnel listed will come to between Rs.3, 000 and Rs.4, 000.
A clinic requires a small section for the education of the public and for the carrying on of anti-venereal propaganda. The education programme to prevent venereal diseases must be broad-based and must be brought to bear early in the life of every youngster.
Monthly returns from all clinics and practitioners treating V.D. cases must be made compulsory. This will help the authorities to direct their efforts according to the needs of each locality. It will also help to establish the incidence of infection.
Each clinic needs to be provided with a mobile clinic or venereal van to cater to the surrounding areas, where clinic facilities are not available. A given area should be regularly covered by these mobile clinics.
FAILURE TO QUALIFY
Taking into account these basic needs of a good clinic, it will be hard to find even one in the country which satisfies these criteria. This is clear evidence of bad planning, lack of imagination and clumsy organization, where V.D. is concerned. The state of the V.D. patients in the E.S.I. scheme, of which so much is heard, is in no way better!
The provision of free and adequate diagnostic and treatment facilities for infected persons is an integral part of a V.D. control programme, and no scheme set up for this purpose will be effective unless the financial responsibility is shouldered by the State. Particular importance has to be given to case-tracing- finding out the original source of infection and bringing it under treatment. However this major aspect is totally neglected in most clinics, for want of a social worker. The treatment must be free and compulsory. Defaulters in the treatment of V.D. are frequent; for an average person considers relief from the symptoms as a “cure”. It is, therefore, important to hold on to the cases till they have been properly tested and declared really cured.
In curbing the scourge of venereal diseases, the Scandinavian countries rank first among the advanced nations of the world. The law requires the reporting of V.D. cases and obliges the infected to receive treatment. It gives the health authorities the power to enforce medical care, penalizes the deliberate transmissions of infection to others and empowers those concerned to find and bring under control all sources of infection. The pre-marital examination of persons intending marriage and their blood testing are compulsory. It is high time that India passed such legislation.
A three- month course in the practice of venereology for the benefit of the general practitioners, so that they may gain insight into the management of venereal cases and may be able to discharge their responsibilities ably. A large number of V.D. patients seek treatment from general practitioners, but the standard of management is generally not up to the mark. Although the private practitioner has always figured prominently in V.D.-control thinking, he is in no position to become a part of the control team in a country- wide effort. He neither reports a case, nor is able to use scientific methods of diagnosis, nor practices contact-tracing or follow-up of the treated. For all this the authorities must develop appropriate procedures to be completed by the practitioners who undertake to treat V.D.
It is advisable for each state to have:
Some three years ago, the then Government of Bombay announced its sanction for Venereal Institute for the State in response to venereologists suggestions. Equipments worth lakhs of rupees was purchased for the purpose. But no thought was given to a place to accommodate the institution. As a result the equipment is lying idle and rushing in the stores, and one does not know when the Institute will come into existence. This is another example of official building.
The institute of 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. The combined diploma in dermatology and venereology, such as we have in Bombay has helped to achieve respectability in neither specialty. On the other hand it has certainly lowered the standards of venereology. It is not uncommon to come across diploma holders lacking even the basic knowledge to the management of a venereal case. This matter was brought to the notice of the University of Bombay some years ago, with the request that it consider the feasibility to instituting a separate diploma in venereology. But the request was turned down. It is to be hoped that one of these days the University will reconsider the suggestion.
Co-operation between venereologists and specialists in other branches of medicine is indispensable. For a good number of patients suffering from V.D. find themselves admitted in medical and surgical, ophthalmic and gynaecological wards for various complaints, the origin of which is venereal disease. Without proper co-operation among these specialists, it will be impossible to determine the exact incidence of V.D. and its complications. Side by side the research on several aspects of V.D. problems has to be undertaken in co-operation with microbiologists, serologists, virologists, epidemiologists and clinicians. Without this, the contribution of the venereologist in the domain of his specialty will not be perfect. He has to develop and maintain steady progress. Today he needs to form a part of a comprehensive medical team, rendering invaluable service in the relief of human suffering.
The wide spread use of penicillin for a variety of venereal conditions has had a profound effect on venereal diseases, in masking aborting and preventing them, as well as in including a carrier stage in the population. It has also led to a reduction in the incidence of complications and suppressions of the early symptomatic stage of V.D. However there has been a distinct rise in the incidence of latent and late syphilis and the value of penicillin in preventing this has proved to be doubtful, creating a subject of serious concern for venereologists and the public health authorities.
But the positive and more spectacular contributions of penicillin have induced something of erroneous and wishful impression in the minds of the health authorities and some medical men, who are not in direct contact with the subject and practice of venereology that these diseases are, dying out, will soon disappear and will no longer constitute a danger to society. This is a very complacent and wrong view, as can be seen from recent reports from medically advanced countries such as U.K. and the U.S., where there has been a marked rise in the incidence of V.D., in spite of the effective control measures in force. In no country, however advanced, has there been any evidence of complete eradication of these diseases. On the contrary, in most they are rearing their ugly heads with what looks like renewed violence. Hence, eternal vigilance is the only remedy and this must be maintained at any cost.
V.D. may not be brought to heal in our time. It will certainly not be so if we fail to recognize it for what it is. Its control depends on a vigorous prosecution of all the elements of the programme: diagnosis, treatment, case-finding, case-holdings, plus sane sex education. The problem requires to be tackled on a national scale, and our policy in regard to venereal diseases needs to be reoriented in the light of modern knowledge.