Sexually transmitted diseases [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION MAY 1975 • UK 45 p • USA $ 1 sexually transmitted diseases 2 20 26 30 Nothing to hide by L. G. Van Parijs Treatment is available by R. R. Willcox Counting the cost by R. C. Rendtorff Cover design by Peter Davies. Contents The worm in the apple by G. Causse 3 New approach imperative by C. N. Sowmini 8 Sex and society by G. Caletti 12 Research in Africa by J. Bidet and A. Siboulet . . 16 Sexually transmitted disease 18 Young World Health . . 34 World Health appears in Arabic, English, French, German, Italian, Per- sian, Portuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. WORLD HEALTH sexually transmitted diseases THE WORM IN THE APPLE The curious fact is that the present revolution in social attitudes to sex has not been matched by the spread of intelligent information on sex BY GEORGES CAUSSE f a man or woman is ill without knowing it or, worse still, feels guil- ty about having caught a certain illness, the chances are slight that he or she will seek medical advice. Ignorance and feelings of guilt are in fact the two staunchest allies of a whole group of infections hitherto known as "venereal diseases". In the hope of mak- ing patients feel less guilty, scientists from all over the world recently agreed to give them another name and chose the term "sexually transmitted diseases", in- evitably shortened to STD. Changing the name does not, of course, change the public health problem in any way. It is a serious problem and one that concerns all countries of the world. As mentioned above, it has as- pects which distinguish it from other contagious disease problems. STD are found everywhere and, if not treated, can lead to serious local or gen- eralized complications that may be very costly for the community. The agents that cause the diseases have been thoroughly identified, an exact diagnosis is usually easy to make, and effective treatment methods are well es- tablished. Despite these advantages, the world prevalence of this group of dis- eases has steadily increased over the last ten to twenty years. Even in countries with well-developed health services, they can break out in epidemics that some- times seem to be beyond control. The union of man and woman as seen by the Norwegian sculptor Gustav Vigeland. This stone sculpture stands in the Vigeland Park, Oslo, Norway. (Photo Vigeland-Museet ) The factors responsible for this situa- tion are at the same time psychological and human, socioeconomic and demo- graphic. The curious fact is that the pre- sent sexual revolution has not been matched by the spread of intelligent sex information. Although the information and communication media deal very freely and in detail with sex matters and everyone's right to sexual freedom, health education seems ill-equipped to tackle the subject and often sadly reluc- tant to do so. The result is that the great majority of the public are almost totally ignorant about these problems. The same is frequently true for the health and administrative authorities, while the training given to doctors and auxiliary health workers in this respect is wretch- edly inadequate. On the clinical side, many more cases are diagnosed and treated but there are also many more relapses, perhaps because the treatment is so rapid and effective. Due to the uncontrolled ad- ministration of antibiotics in too small doses, the disease organisms have grown increasingly resistant. Antibiotic treat- ment may result in still more strains of STD appearing. Social and economic factors Among the factors that may lead to the appearance of new high-risk groups by providing greater opportunities for contacts between the sexes are urbaniza- tion (STD are two to three times more frequent in cities), industrialization, more women seeking jobs outside the home, migrant labour, travel for busi- ness reasons, and tourism. Between 10 and 15 per cent of cases of STD are con- tracted in foreign countries. These facts help to indicate how and where preven- tive action should be applied. It is clear that STD problems should no longer be considered in a purely national context but call for coordinated international measures. Social and cultural developments have combined with the above-mentioned fac- tors to produce changes in attitudes which, in certain sections of society, have resulted in characteristic behaviour pat- terns, whether they are described as "permissive" or as "immoral". Individ- uals are more and more exposed to sex- ual stimuli and young people in particu- lar have adopted new attitudes to sexual behaviour and sexually transmitted dis- eases. The influence which religion, fami- ly, the tribe or public opinion used to wield in this sphere has waned. The ad- vent of new methods of contraception, to a large extent replacing the sheath which also gave some protection against STD, has greatly diminished the fear of preg- nancy outside marriage. Even the fear of infection, which once acted as a restraint, has virtually disappeared because of the rapidity and simplicity of treatment. In consequence, relapses are frequent. It may be that sexual practices themselves are changing—for instance gonococcal infections of the mouth and the rectum are more frequently observed and group sex activities are becoming more com- mon. Homosexuality is on the increase too, and in some countries homosexuals constitute one of the largest high-risk groups with the highest prevalence of STD. 3 The place of STD among the major communicable diseases GONORRHEA 767,215 SYPHILIS V UVPS HEPATITIS CHICKE (91,149) \ PDX TUBERCULOSIS VEASLES RUBELLA SALVONELLOSIS (excluding typhoid fever SHIGELLOSIS I ASEPTIC IV E\ I \GITIS I WHOOPING COUGH RHEUVATIC FEVER (acute) I VALARIA I ALL OTHERS 100 200 300 Source: US Public Health Service, 1974. 400 ti 800 Disease Cases in Thousands Total Number of Reported Cases of Specified Notifiable Diseases 1,312,296 Although sexual freedom has meant that fewer women turn to prostitution in many countries, prostitutes still remain the principal source of infection in cer- tain cities. These social factors affect the beha- viour of individuals and make it harder to trace contacts, who may live in a dense city population or outside the country. Thus, the reservoir of infections that show no visible symptoms or are kept concealed has grown larger and it is this that has led to the increase in new cases now being observed. The tracing of con- tacts must therefore be intensified in ev- ery way both within each country and between countries. Impressive figures Even in countries with well-developed health services, the official notifications give only a poor idea of the true prev- alence of STD. Like the traditional ice- berg, there is a great deal more below the surface than meets the eye. Why is this so? In most countries where private practice exists, between 60 and 80 per cent of cases are found and treated by private doctors. Although required to notify all cases, such doctors usually report only one case in four, perhaps one in six or even one in ten. In countries with poorly-developed services, the health authorities have problems they consider more pressing. Often, therefore, A The striking importance in sheer numbers of STD among other communicable diseases is illustrated in this chart published by the U.S. Public Health Service, showing the number of cases in thousands. United States figures have been chosen as an example because they are among the most detailed and comprehensive. Indonesian mask showing facial paralysis ► caused by advanced syphilis. (Photo WHO) they underestimate or totally fail to rec- ognize the gravity of the STD problem. In some countries with well-established health services, the evolution of STD over the last 10 to 15 years follows a steadily ris- ing curve. However the figures showing this constant rise must take into account several factors, both quantitative and qualitative. 4

the worm in the apple In the USA, for instance, the Pan Ameri- can Sanitary Bureau has estimated that in 1973, when about 800,000 cases of gonococcal infections were notified, the actual total exceeded 2.5 million out of a population of 250 million. There is good reason to believe that the same is true in several other countries. Studies of the distribution by age- group in several countries bring out an even more important point. The prev- alence of STD in the 15-19 group is twice as high as in the whole population. In the age-group 20-24 it is four or five times as high, and in the 20-29 age-group it is twice as high. These figures relate to the USA. They are cited here not because they are more alarming than elsewhere but because the statistical and epidemio- logical data are detailed and complete. In the 15-30 age-group, the incidence of gonococcal infections in most coun- tries is between 1 and 5 per cent. Recent surveys show that in countries with poor- ly-developed health services, it varies from 6 to 10 per cent, and is even higher among certain high-risk groups. The incidence of syphilis, whose long- term effects are much more serious, is fortunately 10 to 50 times less frequent but its distribution by age-group follows the same pattern. In the last few years, however, there has been a disturbing re- crudescence of this disease. According to surveys sponsored by wHo, both syphilis and gonorrhoea are found throughout the world and both are particularly com- mon in those countries where little at- tempt is made to prevent them. One survey in a number of Asian countries showed that between 20 and 55 per cent of the university students who were canvassed had contracted a gono- coccal infection within a one-year period. The same infection was found in 17 per cent of the women attending fami- ly planning centres in countries of Cen- tral Africa, although they showed no symptoms of the disease. The absence of symptoms represents one of the principal difficulties in the control of gonococcal infections. Be- tween 70 and 80 per cent of women and between 10 and 20 per cent of men infect- ed with this form of STD have no notice- able signs of it yet remain contagious and may develop local or generalized compli- cations. What about the world distribution of other forms of STD? Soft chancre, which used to be com- mon everywhere, has now become rare in western countries although outbreaks have recently been reported in Europe and especially in France. In the Far East, in Africa and in many other regions it still poses a serious problem. Granuloma inguinale (a small round swelling in the groin) is found occasion- ally in Europe but is common in inter- tropical regions and endemic in southern India and in Papua New Guinea. Lymphogranuloma venereum (a dis- ease of the lymph nodes) is widespread but of infrequent occurrence and is en- demic mainly in ports of South America, the Caribbean, the west coast of Africa, and Madagascar. Widespread and serious as they are, most of the last-mentioned forms of STD are seldom notified. The same is true of non-gonococcal urethritis caused by chlamydia, a microorganism of the order of the Rickettsiales which is responsible for genito-urinary and eye infections in man. It is a widespread condition, often associated with gonococcal urethritis but even more common. Among people at- tending STD clinics with urethritis, 60 per cent had chlamydia and 30 per cent gonococci. In 63 per cent of cases, the two agents were found together. Serious complications What is more, between 5 per cent and 8 per cent of women examined in family planning centres and showing no symp- toms were found to be carrying chlamy- dia. Doctors often fail to recognize this disease although it can lead to serious complications in the pelvic region or of a generalized nature. They include Reiter's syndrome which may cause acute, sub- acute and chronic rheumatism, uveitis (inflammation of the eye or the pigment- ed layer of the iris) and heart troubles resulting from impairment of the valves or the aorta. Sexually transmitted diseases, particu- larly syphilis, gonococcal infections and non-gonococcal urethritis, are among the most frequent in the world; they are exceeded only by influenza during epi- demics, malaria and schistosomiasis. The gravity of the public health prob- lem they constitute is due mainly to the seriousness of the complications occur- ring in infected but untreated persons. Even in countries with well-developed health services, between 10 and 20 per cent of women with gonococcal infec- tions have been found to suffer from pel- vic complications, and the causative agent, Neisseria gonorrhoeae, has been detected in 90 per cent of women admit- ted to hospital for a first attack of acute pelvic inflammation. Outcome: Sterility In a large percentage of these cases, the outcome is sterility which is often permanent. There are grounds for believ- ing that, in countries with poorly-devel- oped health services, between 20 and 30 per cent of cases of sterility, and perhaps more, are due to gonococcal infections. Other STD such as soft chancre, gra- nuloma inguinale or lymphogranulum inguinale may be responsible for ulcers that appear either locally or at a distance from the site of infection. Genital herpes, which is more common than syphilis but less so than gonococcal infections, par- ticularly in the form caused by the type 2 herpes virus, is very harmful because, apart from causing encephalitis in the newborn, there seems to be a strong cor- relation between this virus and cancer of the cervix. The consequences of inadequate or non-existent treatment are very costly for the community. They include the need to provide hospital services and long-term care for patients suffering from acute or disabling complications. Women may become sterile and there is even the risk of premature death. By comparison, the cost of any STD eradication programme is relatively light. A cost-benefit analysis of simple and practicable control programmes using known and tried techniques shows that the community would reap considerable socioeconomic benefits from them, quite apart from protecting every individual's right to enjoy good health. The number of cases of STD is on the rise in all age-groups, but is much higher among young people, particularly those living in large cities or belonging to par- ticularly high-risk social or professional groups. It is clear that the essentially medical control methods used at present have had only limited success and have certainly failed to reverse the trend. In any attempt to control STD, the main point to be remembered is that the epidemiological equilibrium between the factors favouring the spread of the dis- ease and those reducing it is most pre- carious. Even a minor change in the con- ditions of the contest may have a dispro- portionate effect on the trend. Personal behaviour is a major factor in the spread of STD, but it is so intimately linked to the psychosocial environment 6 gardez-vous des MARES VENERIENNES Young people are particularly at risk in all countries and cultures. A successful health education poster produced by the French National League Against Venereal Diseases. (Photo WHO) LIGUE NATIONALE FRANCAISE CONTRE LE PERIL VENERIEN INSTITUT ALFRED FOURNIER • 25 BOULEVARD SAINT-JACQUES • PARIS and the individual's adaptation to soci- ety, that it is hardly possible to change it except by a long-term social and medical programme concentrating on education and prevention. On the other hand, it would be highly desirable to make a more systematic use of available methods for detecting cases that present no overt symptoms. This should be done whenever patients are given serological, clinical, and especially gynaecological, examinations. Well-or- ganized case-finding would in turn make it easier to track down contacts, given the cooperation of patients. Just as important is the development of sex education, provided it is done in- telligently and avoids moralizing or in- ducing feelings of guilt. It should aim at informing the public about the sTD problem in the community, exploring the advantages of the available preventive or curative measures to the groups at risk, educating young people so that they un- derstand the health aspects of their sex life, and encouraging the patient to over- come feelings of guilt and to accept his or her responsibilities towards the commu- nity. The overriding aim is to obtain the active participation of individuals and groups in efforts to control sm. Programmes of this kind, designed to inform and to motivate, have been un- dertaken in the socialist countries and elsewhere and have succeeded in quite a short time in appreciably reducing the incidence of sm. Educators, psycholo- gists and sociologists as well as doctors are needed both in preparing and in ex- ecuting them. A first step is often to teach the educators or to give existing health education staff additional training or retraining. The development of effective anti- biotic treatment has made it possible to a large extent to prevent later complica- tions, particularly those of syphilis and gonococcal infections. Yet that result has still not been achieved in certain regions where manpower and financial resources are limited. It is therefore urgent that the gravity of the situation should be made known and that international assistance should be forthcoming for such regions. The creation or the improvement of sTD control centres, their integration in the overall system of communicable dis- ease control, and the supply to medical and auxiliary personnel of technical in- formation, as well as simple but effective means of diagnosis and treatment, are all essential elements in any rational ap- proach to the problem. There is some hope that continuing research will eventually develop vaccines against sTD and will provide specific protection for individuals.The question will then arise of to whom and under what circumstances such protection should be offered. However, the prospect of making progress in this direction must not prevent or inhibit the immediate ap- plication of such presently available diagnostic, therapeutic and educative methods as have already proved effec- tive. Throughout the world, even now, it should be possible to make sound pro- gress and to reverse the present trend of sexually transmitted diseases through the rational use of existing knowledge and resources and, in the less privileged countries, of international cooperation. Indeed, if there are few communicable diseases that are more widespread and more harmful to the individual and to the community than sTD, there are few- er still against which we possess so many means of effective action. ■ 7 new approach imperative Teaching people how to deal with STD often meets initial resistance. A pilot programme in Madras finally won over community leaders and doctors BY C.N. SOWMINI he incidence of sexually transmitted diseases is spiralling, even though we know that they are preventable, controllable and curable. What a paradox ! Somewhere we have failed to tackle this problem in its right perspective. But where? Let us take stock of all that we have done so far and what we have left undone. Diag- nosis, treatment, occasional case-finding and imparting information about sexually trans- mitted diseases (STD) were considered as management and control. We have missed the root causes which are implanted deep in the community. Unless these deep-rooted factors are tackled, sexually transmitted dis- eases are bound to exist and multiply, with cumulative effect on the community and in- directly on the individual. In our Institute of Venereology at the Madras Medical College, after three decades of management of STD, we felt that it had become stereotyped and a dead end had been reached. We felt isolated and ineffectual. So a new approach became imperative. Since the root causes were in the community, we realized that our activities should start more from the community than from the hospital. With this idea we left the confines of the hospital and went out into the community to discover the best way of adding another dimension to the prevention and control of a disease—closely linked to a delicate beha- vioural problem of mankind—by means of a community-centred programme. The emphasis of the programme was on health education. We drew up a plan in con- sultation with the Health Education Bureau and a Research-cum-Action Project. Finan- cial support came from the Indian Council of Medical Research. Selection and study of the community and the collection of epidemiological data as a prerequisite engaged our attention first. We chose Halls Garden, a small community of 3,700 population situated in the heart of Madras City, where the people in the risk group of 15-50 years numbered about 2,000. Hindus, Christians and Muslims constituted the community in the ratio of 5, 3, 2. Most of them were labourers, skilled or unskilled, with an educational level varying from pri- mary to secondary. Their average monthly income was 300 rupees (about 37 US dol- lars). Houses were overcrowded and ill-venti- lated, lacking such basic amenities as toilets and water supply. Streets were narrow, with no proper drainage or maintenance. People moved in and out of the community fre- quently in search of jobs. The heterogeneity of the population and its high mobility meant that social unity and neighbourhood organizations were rather diffuse. The community was served by the health services of the City of Madras Corporation, and had a welfare centre run by the St George's Cathedral. Nearby was Royapettah Hospital, one of the major hospitals of the city. The presence of these agencies was one of the main reasons we selected this commu- nity, and we found them very useful to our programme. The greatest challenge to any team that undertakes a project of this nature is to ob- tain the active participation of the communi- ty, therefore the first and most important step was to establish contact with the com- munity leaders. We paid special attention to their priority needs such as drainage, envi- ronmental sanitation and a medical health check-up. Their suggestions for a health check-up and treatment were welcomed. We had thought that, especially in the initial stage, the programme might not be accepted if it were projected as one concerning only sexually transmitted diseases. We arranged information sessions on STD for the community leaders at the Health Ed- ucation Bureau and the Institute of Venereology. Though the theme was mainly STD, basic information regarding other medi- cal conditions was also given since the leaders showed interest in them. Having established a positive relationship with the key personnel of the community, we made a baseline survey of the knowledge and attitude of the people towards STD. A ran- dom sample of ten per cent of the people aged from 15 to 50 were selected and inter- viewed in private by specially trained inter- viewers. Only 19 out of 200 respondents in the sample either refused or did not make themselves available. One lady objected to Ancient Hindu art knew how to depict with serenity the ecstasy of sexual love. Healthy attitudes to sex, based on mutual respect, must replace the random sexual promiscuity which in some sub-cultures today is partly responsible for the rising tide of STD. (Photo WHO) 8

her unmarried son being questioned on the grounds that it was an indirect way of advo- cating family planning. She also prevented other respondents from being interviewed. Another lady objected to her teen-aged son being asked "vulgar" questions. The study showed that most people were familiar with the local term "Pompla Vyad- hi" meaning venereal disease and could de- scribe the symptoms of sip—sore, discharge, bubo, burning sensation while passing urine and difficulty in walking Forty-one per cent of respondents knew of friends, relatives or acquaintances who had had sm ; two per cent reported that they themselves were vic- tims. Gonorrhoea seemed to be better known than syphilis. The fact that many people in the commu- nity were familiar with these diseases, and used colloquial terms for them, made com- munication of ideas easier. We directed our efforts towards teaching people that the symptoms of STD which they were able to identify were early symptoms, and that it was important to report for treatment when they noticed such symptoms. Many people knew that these diseases are sexually transmitted and the fact that the majority advocated abstinence from illicit relationships as a means of preventing them suggested that traditional values of morality still prevailed. But in practice large numbers do not live up to these social values and these were therefore our concern. We highlighted in our education programmes the impor- tance of a health check-up for the individual and his family as soon as early symptoms of STD were noticed. We also advised couples to protect themselves by using a condom. Sixteen per cent of the respondents reported using the "Nirodh" (condom) in order to prevent STD. This was significant, since it was only during the last six to seven years that Nirodh had been popularized as a fami- ly planning method. Though use of a con- dom does not ensure 100 per cent protection, it is still recognized as an important method of protection for individuals in the STD con- trol programme. Nearly a quarter of the respondents reported that suitable injections taken before and after exposure could help prevent STD. This finding strengthened the earlier observa- tion of our interviewers that people often treated themselves or sought treatment from quacks. We advised them to go for treatment to the Institute or other hospitals, or to quali- fied doctors. Almost all the people interviewed stated that treatment was necessary for the cure of "Halls Garden", a small district of 3,700 peo- ple situated in the heart of Madras City— scene of a striking experiment in community health education. (Photo WHO) such diseases, but they were reluctant to go to hospitals, and cited fears of being inter- viewed on personal matters, facing rude or unsympathetic comments, being teased or scolded by the staff, being stripped naked for examination, having painful injections or blood tests, or having ulcers examined. Some feared publicity while others were shy or em- barrassed about being examined in case they were infected. We felt it was important to help the people to form a correct image of sm clinics and hospitals. We explained the type of services offered at the clinics and how these were essential however unpleasant they might be; examinations were carried out in private and the findings kept strictly confidential. We also understood the need for paying greater attention to training staff in the proper atti- tudes and skill needed for dealing with patients. Most people wanted to know more about STD from health personnel. The staff orga- nized talks, group discussions, exhibitions, dramas and film shows. Flip charts, pamph- lets and posters helped to make the teaching more effective. Special programmes were ar- ranged for community leaders, the staff at the community centre, members of the Mother's Union, and young girls in the age group 15 to 25 who were attending sewing classes. One of the main features of an sm con- trol programme is to get medical men in- terested in the problem and to change their attitude so that they can deal with it with a deeper understanding of psychological, sociological and ecological factors. As the community lay within the jurisdic- tion of the health services of the City of Madras Corporation, it was essential to en- list the interest and cooperation of the doc- tors and their auxiliary staff attached to the Corporation's maternal and child welfare and family planning clinics. They were given training at the Institute so that we could share with them our experiences in commu- nity education. Though health education was the main objective of the programme, health check-up and subsequent treatment were undertaken as suggested by the community leaders. The house-to-house health check marked the beginning of the extension of the hospital services to the community. A clinic in the community centre was next established to serve as a link between the community and the Institute. Epidemiological investigation took place on a limited scale. We interviewed the STD sufferers in the community individ- ually and in privacy, and found that al- though prostitution did not exist in the com- munity the source of infection was a group of clandestine prostitutes outside the communi- ty. One adolescent revealed that four of his associates had also been exposed to risk with him. All were identified and brought for ex- amination. Two had previously had gono- coccal infections and had been treated in the nearby hospital. During one of the group talks with male adolescents, two procurers living in and around the community were identified. One was partially blind and spent most of his time under a shady tree. He was persuaded by the staff to attend the Institute and, on examina- tion, was found to be suffering from bilateral syphilitic optic atrophy. While he was an in- patient he had the benefit of repeated coun- The Halls Garden community responded quickly to the health workers' inquiries. They wanted to know more about STD through group discussions, lectures, exhibitions and filmshows. The time and place of meetings like this were arranged to suit the convenience of the people concerned. (Photo WHO) selling by the social worker, and on being discharged from the hospital he moved away from the community. The other procurer proved difficult to trace. Evaluation formed part of our total plan from the outset. Our main concern was to feed back the field observations and ex- periences through periodic staff discussions and use them to improve the later stages of the programme. Goals and activities which had seemed only vaguely discernible became clearer as we progressed. One of the main consequences of this programme was that it provided an opportunity for the staff and students of the Institute to have experience with a community programme. It added a new dimension to their understanding and ability to deal with the problem. Those doc- tors who had to be coaxed in the beginning are now eager, and have volunteered to con- duct the community clinic as part of their regular work. Their attitude towards patients has also noticeably changed. Training the health personnel of the City of Madras Corporation was a side-product of the community programme, and the re- sponse to this training has been good. Now we plan to extend the training to the entire staff and to encourage them in building up STD education and services as an integral part of their maternal and child health and family planning programmes. ■ 1 1 sex and the new society A sexual adventure is considered, particularly by men but increasingly by women too, as the logical happy ending to a holiday or a journey BY GIOVANNI CALETTI n the last 20 years society in many countries of the world has undergone great changes. Because of industrial- ization and technological develop- ments many previously unhoped-for goals have been reached in different fields of pro- duction. Nor has medicine been overlooked for it has benefited by the discovery of powerful drugs and extremely refined methods of research. Keeping pace with all this, there have been upheavals within the family itself, in the way of living, in the way of looking at life, in the economic position, in culture and in moral values. One of the most noteworthy con- quests has been the greater expectation of life because of the decrease in the infant mortali- ty rate, the discovery of antibiotics that have made many infections harmless, and the im- proved standard of living that has been reached in many countries. Industrialization and all that it brings with it has changed the character even of the fami- ly and the relationship between its members. Generally there has been a widening of hori- zons together with a much greater awareness of social and work problems than in the past. But in the modern consumer society, ad- vances in technology and industrialization have driven the masses to make a god of consumer goods as if inner values—spiritual, cultural or political—did not exist. Young people tend more and more to fol- low and copy the ideas and life style of peo- ple of their own age rather than the authority and experience of their parents or teachers. Often they are disillusioned with the beha- viour of adults and criticize their contradic- tions and hypocrisy. Parents do not fulfil their obligations ei- ther in informing their children about sexual problems or in helping them to acquire a responsible attitude towards this important factor in life. This is partly because they are unable to talk openly and frankly with their children and partly because they haven't time. Consequently, both boys and girls are initiated by older companions who pretend to be very knowing but may not be the most suitable people to impart information. This results in sexual behaviour that is both irregular and unsatisfactory because it has no lasting basis and springs from chance stimuli rather than from a sense of responsi- bility. It is against this background that young people today have their first conquests, their first experiences of love and also their first disappointments. Sexual relationships echo the tempo of modern life. They are hasty, aiming at concrete advantage rather than a personal enrichment and a deepening of feel- ing and knowledge between people of dif- ferent sex. The so-called sexual revolution that should have given equal dignity to man and woman, that should have done away with male privileges (particularly evident in Latin countries) and given a richer and deeper meaning to sexual intercourse (the most human and complete relationship that exists) has degenerated into eroticism and pornog- raphy. The deficiencies of the family, the indiffer- ence of educationalists and social injustices all leave their mark on human personality. We must not think that men and women today are morally worse than they were in the past; in fact there are some signs which point to the opposite. Man's sense of solidar- ity, his interest in the poor, his active partici- pation in the world of work show that pro- gress is being made, even if with difficulty. But mankind appears to be rushing headlong towards an erotic and disturbed society that is losing its human dimensions and leaves little time for culture and inner needs. The pursuit of pleasure as an escape, as a flight from responsibility and the difficulties of life, is becoming more and more frequent. In special circumstances, for example when travelling on holiday or business, we come face to face with different people and experiences and circumstances for which we have not been prepared. Our personality comes out clearly in the way we behave, per- haps most of all in our sexual behaviour. Common sense, prudence and loyalty are of- ten lacking in our relationships with other people. Tourism has become a need, even a habit: in 1973 more than 215 million people crossed the various frontiers. There are countless op- portunities for meeting people, and especial- ly people of the opposite sex, in youth hos- tels, on beaches, in holiday clubs, on the plane, in the train, perhaps hitch-hiking. Very often days or weeks spent in the sun together with new friends in new countries lead to sexual intercourse as a natural con- clusion. A sexual adventure is considered, at least by men (but girls are also beginning to think in the same way), as the logical happy ending to a holiday or a journey. Young people (but not only young people) very often forget that every rose can have its More than 215 million travellers crossed national frontiers during 1973. The advent of worldwide tourism has brought an entirely new set of stimuli and exotic excitement within range of many people, and has contributed to the changing pattern of social behaviour. ( Photo Len Sirman ) 12

thorns and that sexual intercourse with peo- ple one hardly knows can be fraught with dangers of disease. This lack of foresight and of a sense of responsibility is often due to the fact that young people (and it is these who suffer most from sexually transmitted dis- eases) have very vague ideas about sex-mat- ters and for the most part are ill-informed on the question. Tourism, a phenomenon of our consumer society, has become an occasion for relax- ation, an opportunity to improve our per- sonal culture but it can also be the cause of infection, just as it is for other diseases if we don't take care and follow the necessary pre- cautions. There are, indeed, very good rea- sons for the international regulations that make vaccination against certain diseases such as typhus, cholera, yellow fever and smallpox compulsory. Unfortunately, there is as yet no proven vaccine against sexually transmitted infections. Once such diseases were largely spread by prostitutes. Today it can be reckoned that 30 per cent of these diseases can be attributed to this source (at least in Latin countries) while the percentage may even be lower in many countries. We must not forget that even a young girl, a school friend or work fellow, may unwittingly be the carrier of a sexually transmitted infection. As I have devoted myself to the study of these problems on behalf of the Venereal Diseases unit of WHO, I can give some data that health authorities in various countries have sent me. In Italy, for example, it has been calculated that 10 per cent of recorded STD cases derive from tourism, that is, they are cases of Italians (both male and female) who have contracted the infection abroad or from foreigners in Italy. Finland reported that in 1973, 27 per cent of the cases of pri- mary syphilis and 5 per cent of the cases of gonorrhoea were imported. Although no percentages are available for Poland, it is stated that cases exist where infection was picked up abroad. England and Czechoslo- vakia too confirm the existence of this phenomenon. In Denmark 325 cases of syphilis were reported in 1973 and 82 of these were caused by infections caught abroad. Belgium and Holland both state that many cases of sexually transmitted infections can be linked to tourism. It is rather different for a migrant in a foreign land because of his state of mind and his lack of financial means. For him sex is often a consolation, the desire for compa- nionship and an opportunity to assert him- self. A new life brings with it a chance to move about, to travel, and to visit new places. The problem of immigrants must be ex- amined from a different point of view. In theory an immigrant can carry with him a sexually transmitted infection from his coun- try of origin but in practice this is almost impossible because of the medical examina- A Sand, sea and the sun. Tourists in quest of holiday pleasures cheerfully accept the con- straints of a crowded campsite. By contrast, they are freed from the social or moral res- traints of home. (Photo WHOIPublifoto) All the world loves a lover. To ensure that the attractive picture of young love is not ble- mished by the shadow of STD, everybody concerned—especially in the high-risk age- groups—must be taught about the health hazards involved. (Photo L. Sirman ) tions and controls that are carried out. Sta- tistics have proved that immigrants quite of- ten become infected in the host country. The psychological situation in which an immigrant finds himself—very different from that of a tourist—may lead him to seek an escape from his loneliness so that incautious- ly he picks up an unknown partner and is easy prey to a sexually transmitted infection. When he goes home on leave, he may unwit- tingly carry the infection to his own family. The current spread of these diseases is all the more strange when we remember that nowadays there are powerful medicines and very precise means of diagnosis. To combat them it is necessary to educate all our citizens, at all levels and all classes, and to create in them a sense of responsibility. It is the duty of society to educate all citizens in these matters and to help them acquire a 14 Kondome sired (2X.- Kondome Stheitzen. conscience about health and society so that we can achieve those successes that so far doctors alone have been unable to obtain. A campaign against STD must reach as many people as possible, particularly parents, youth leaders, teachers, club mem- bers, and personnel of the armed forces. As far as tourism and immigration are concerned some simple guidelines may be useful in making the people who run the greatest risk more careful. When it is a ques- tion of group travel, the leader of the group must draw attention to the danger of all the diseases tourists may encounter including those transmitted as a result of sexual inter- course. In youth hostels and camping grounds automatic machines should be avail- able for the sale of contraceptive sheaths. In amusement arcades and in toilets at places where tourists gather together, posters and notices should be displayed clearly indi- cating dispensaries where the infected can be treated. In some countries it is possible to dial a special telephone number to obtain information about the symptoms of the dis- eases as well as places where treatment may be obtained. Travel brochures should mention in the information they give about health the prob- lem of sexually transmitted infections. This has already been done by the Belgian author- ities without shocking anyone. It must not be forgotten that the use of the pill—even if it has avoided the danger of unwanted pregnancies—has to a certain ex- tent favoured the spread of STD. Where for- merly many men used a contraceptive sheath so that the girl would not become pregnant, this protected them at the same time from possible infection. The problem is more complicated as far as immigrants are concerned and must be stud- ied both in the country of origin and in the host country. In the country of origin where there is an excess of labour, those people who have to go abroad to find work must be prepared very carefully with special reference to every human problem. They should be given a knowledge of the language and cus- Swedish health education cartoon in favour of the condom whiCh prevents disease as well as being a safe instrument of family planning. toms of the host country and should be urged to behave responsibly in their sexual rela- tions. A point to remember is that an immi- grant who is accompanied by his family is more stable and less likely to go in search of adventures. When a worker can adapt him- self easily to the host country, he is more aware of social problems and more ready to respect local habits and customs. A wHo-sponsored meeting on health edu- cation in the control of sexually transmitted diseases agreed in Geneva last November that the medical response to the present worldwide "epidemic" has so far proved in- effective. Some 50 experts from 25 countries concluded that, although there was no inten- tion of dismantling the technical means al- ready available to fight these diseases, the world must resort more incisively to educa- tion. Physicians, nurses, midwives and other members of the health team should receive necessary training in STD control, while health education of the public, particularly of the young, should be objective, realistic and offered without a moralizing tone. Sex- ually transmitted diseases will also form the subject of technical discussions during the World Health Assembly in Geneva this month. Finally, all sectors of society must collabo- rate to make everyone aware of these partic- ular health hazards and problems and to create a new sense of responsibility towards them. ■ 15 research in west africa A WHO-sponsored research project on yaws and endemic syphilis in Senegal has stimulated new studies of other West African health problems BY J. RIDET AND A. SIBOULET ommunicable diseases, including sexually transmitted diseases, still pose the main challenge to public health in several continents. They are directly responsible for high rates of infantile and juvenile mortality and often present a hindrance to conomic and social development. To be effective, the control of these diseases must be planned on the basis of realistic data about the present and long- term situation. The study of communi- cable diseases is therefore an essential element in the planning process. Howev- er, in countries where health services may be rudimentary, statistical data are often incomplete and inaccurate. Yet it is these very countries which can least af- ford to delay their programme planning. The principle of epidemic study and surveillance has been developed with the specific aim of obtaining vital informa- tion required for planning control pro- grammes and evaluating the results. After assisting large-scale campaigns against endemic syphilis and yaws (a dis- ease, like endemic syphilis, due to a spi- rochete, but transmitted by contact from sick to healthy persons), wHo launched an international field research project in 1968 to determine the extent of these dis- eases, particularly in Senegal. Blood tests carried out under this project have made it possible to conduct multi-purpose im- munological studies whose aim goes beyond the control of these diseases. In order to find out the prevalence of a disease in any population, a sample group is selected by statistical methods and all those in it are subjected to a thorough examination for any clinical manifestations. Blood tests will reveal the immunological effects of infection and show up any latent cases. Ecological, social and economic conditions as well as the social structure of the community all have a bearing on the course of diseases and therefore form part of the study. A dual survey of this kind was carried out in Senegal in 1972, with the approval of the Government. One aspect covered yaws in the Casamance Region where the disease is fast disappearing, the other, endemic syphilis in the Senegal River Region. The object was to restore the economy of the river valley and the pro- ject was launched under the auspices of an organization representing the states bordering the Senegal River and the ad- ministration of Casamance. The success of this project and the scale of public health problems other than yaws and syphilis in these areas en- couraged further studies, in cooperation with the health authorities, similarly based on clinical and serological exami- nations. These are particularly concerned with viral hepatitis and with the arbo- viruses, which include yellow fever, sleeping sickness (trypanosomiasis), ma- laria and brucellosis. A number of other health problems have been the subject of similar surveys, among them dental caries and infantile malnutrition in drought- stricken areas. Lastly, an investigation of female geni- tal infections and male gonococcal infec- tions in town and country has been start- ed in collaboration with the Experimen- tal Bacteriology Laboratory of the Pas- teur Institute in Dakar. This project also offers an opportunity for studying ways of making public information and health education available in semi-rural areas. Preliminary results In less than two years, the epidemio- logical team has taken a total of 10,000 specimens—examining more than a hun- dred people at each of a hundred locali- ties. Each person examined freely agreed to answer questions about his or her state of health past and present, and to undergo a clinical examination including a blood test. At the same time, the team made sure in each village it visited that all cases of sickness were diagnosed and treated if no health centres were within reach. The mass treatment campaigns of 1957-1960 resulted in the complete clini- 16 sAIP, .1•••• .t.,ff • • cal eradication of yaws. The immunolog- ical consequences (as shown by positive blood tests) occur in 4.5 per cent of the population, but have only been found in adults. But in the Senegal River areas bordering the Sahel, 2.5 per cent of recent cases of endemic syphilis were found among children, while 21.1 per cent of all cases showed positive serolo- gy. This proves that the disease is still being actively transmitted and that active surveillance is essential. Many cases of sexually transmitted syphilis also came to light and there ap- pears to be a real danger of this disease spreading. The prevalence of gonococcal infec- tions proved to be as high as 10.6 and even 18.7 per cent in some areas, fre- quently with additional complications resulting from the lack of or the inade- quacy of treatment. Among the women particularly, there were many cases of salpingitis and it seems probable that many of these may result in incurable sterility. Some 30 per cent of the cases detected among regular attenders at maternal and child health centres pre- sented no symptoms at all. The children often suffer from con- junctivitis, and gonococci were found in conjunctival samples taken from some of them. The increasing influx of tourists to Senegal favours the transmission of STD. According to the Dakar Tourist Office their numbers rose from 70,000 in 1971 to 110,000 in 1972 and 120,000 in 1973. More and more hotels are being built as well as holiday camps, and these raise problems which will require special attention. On the other hand, the number of cases of gonococcal infections and syphi- lis among prostitutes appears to be small. Information obtained from the military authorities confirms that more than half of all gonococcal infections are due to casual sexual encounters. Discarding customs The intermingling of populations plays an important role in the transmis- sion of STD. In many areas the trend in young people's behaviour is towards a loosening of family ties, a decline in re- spect for religious belief, and the discard- ing of traditional customs. This situation in turn favours sexual promiscuity. Ig- norance of the health risks involved is almost universal. Doctors and pharma- cists who were questioned said that "young people don't come and consult us until their infection produces compli- cations", and even the possibility of pre- vention by using male protectives is vir- tually unknown. Communications are seldom a simple matter. Here the project vehicle used for transporting research workers studying STD control in West Africa is driven on to a barge to cross the river Senegal. ( Photo WHO) Lack of information ensures that peo- ple remain in ignorance and perpetuates irresponsible attitudes. The lapse of time between the first appearance of a clinical sign and consultation is at best rarely under ten days. There is thus an urgent need in Sene- gal—as in most countries throughout the world—to propagate simple, accurate in- formation about these diseases and to launch sensible health education pro- grammes that will reach all levels of soci- ety, whether they are students at Dakar or Fula nomads. The Senegalese health authorities are particularly alive to the problem and are providing considerable support for this work. A health educa- tion team which was formed recently, for example, has already made remarkable progress. Radio programmes in Casamance, produced with the help of the health edu- cation authorities, also seem to be pro- ducing results. The regional officer, Mr. Kemo Sane, reported a significant in- crease in the numbers of gonococcal in- fections diagnosed and treated since the public information campaign began. ■ 17 MAJOR SEXUALLY TRANSMITTED DISEASES SYMPTOMS DISEASE PERIOD OF INCUBATION PATHOGENIC AGENT Uro-genital inflammation In men, urethritis — inflam- mation and purulent dis- charge from genital organ, pain on urinating, urine sometimes turbid. In women there is some- times vaginitis (inflammation of the vaginal mucuous membrane). However, urethritis may be present, contagious and li- able to complications with- out presenting any particular symptoms. Gonococcal urethritis, gonor- rhoea; the throat and anus and skin may be affected. Non-gonococcal urethritis due to Mycoplasma. Urethritis due to Trichomonas vaginalis. Urethritis due to Chlamydia. Urethritis due to Candida; balanitis (inflammation of the glans penis) and vaginitis. Uncertain (4 days to several months) 3 days to 1 month. Several days (often not known). 3 days to 1 month. A bacterium called gono- coccus or Neisseria gonorrhoea. Bacteria known as Myco- plasma (strain T. and M. hominis). A protozoa (unicellular parasite) Trichomonas vaginalis. Chlamydia (micro-organism similar to the Rickettsia, responsible for genito-urinary and ocular infections. A yeast (unicellular fungus) called Candida albicans. 2 to 6 days. Syphilitic chancre: with a hard base but painless, may occur in the anus, on the lips, tongue or tonsils. It is follow- ed by adenopathy, ganglions in the groin if the chancre is genital. Chancroid: painful, with soft base, deep localized ulcera- tion on genital organs, ac- companied after several days by adenopathy of the groin which may become ulcerated. Chancre: 2 to 4 weeks, or more. Secondary syphilis: (second stage if the primary stage is not treated): 3 to 14 weeks. Late syphilis: from 5 years. 2 to 5 days. Treponema pallidum or treponeme, a micro-organism of the spirochetes family (long, flexible and undulat- ing). A bacterium: Hemophilus ducreyi : Ducrey's bacillus. Chancre Ulceration at the site of entry of the infection, usually in the genital region. Genital ulcerative lesions. { 2 to 7 days, sometimes more. Genital herpes. Herpes virus type II Adenopathy (growths in the lymphatic ganglions of the groin) with or without genital ulceration. Lymphogranuloma venereum (Nicolas & Favre). Genital ulcerations; adenopathy. Granuloma inguinale (Donovan) (a small, round- shaped tumour in the groin). Adenopathy and enlargement of the spleen with fever. 5 to 25 days, sometimes more. A few days up to several months. Chlamydia. A bacterium, Donovania granulomatis (Calymmato- bacterium granulomatis). Cytomegalovirus of the herpes virus group. 18 The agent of syphilis: a long, flexible and undulating micro organism of the spiro- chetes family called treponema pallidum. A unicellular parasite or protozoa known as Trichomonas vaginalis. Shaped like a coffee bean, a bacterium called gonococcus or Neisseria gonorrhoea. Agent of the most common form of ure-• thritis. (drawing by artist Peter Davies.) COMMONEST COMPLICATIONS In men : prostatitis, epididymitis, stricture, sterility. In women: metritis of the cervix — annexitis, sterility. Men and women: arthritis — dermatitis, conjunctivitis of the newborn. In women: salpingitis, miscarriage, puerperal infec- tions (affecting women in childbirth). In men and women: salpingitis, epididymitis. Reiter's syndrome (conjunctivo-urethro- synovial). Arthritis, uveitis (eye inflam- mation), valvular lesions of the heart and cardiac insufficiency. Cystitis (inflammation of the bladder). Endometritis (inflammation of the internal mucosa of the uterus). Skin and mucous, nervous or abdominal complaints, death of foetus, congenital syphilis. Destruction of tissue: suppurative dis- orders and lesions of the lymphatic ganglions (adenopathies). Meningo-encephalitis (infection of new- born). Cancer of the cervix. Ulcerative lesions of the genital organs (adenopathies, strictures). Ulcerations in the genital region and groin. Lesions of the bone. Transmission to the child through the placenta, and nervous disorders. nothing to hid Public attitudes are still too much based on the assumption that STD are afflictions peculiar to loose men and women: "decent" people don't catch t4volv- BY LUK G. VAN PARIJS ...- .... ' P ..,.. • ,... .... 410040,111•' ....01111V.k...::aleo......................... • ..... ow 40 40, .^ a or . a ob.' 4... in...........-,........r v.,. 0, 4.. ...0,4„, s . . -.sz ,,, .............;:-......;?;,...,;‘,.....r.4rogrer, A ga t. ' .10111114:4■5411. e 114 IS" 411'10 VI: 1110 ■ 0 -■ :46.41111:1::: 40 40 410 ID • 10 0 1.4111- 2.4-1::04.4"1 ji 115011 .11:411::: I :11 #1.4 i'. ,- a 0 .00104.70/074iN Illb ost countries of the world report rising trends in sexually trans- mitted diseases despite the exist- ence of modern treatment which is effective and often freely available. Several explanations have been offered for this para- dox and most of them emphasize that these diseases are closely related to human behav- iour as well as to social and cultural condi- tions. Some even prefer to call them a social and behavioural problem rather than a strictly medical one of communicable disease. The role of health education in STD con- trol is to clarify these behaviour patterns and the conditions that give rise to them so that ways and means can be found to give all population groups the best possible chance to keep healthy and avoid them. Four main types of behaviour have a bear- ing on the natural history of these diseases and are critical to their prevention, spread and control. Firstly, sexually active persons must real- ize that they run a much higher risk of being infected and of spreading the disease if they choose their sexual partners casually and change them frequently. This is often the case with people who for reasons of work or leisure are regularly absent from their fami- liar milieu: migrant workers, seamen, sol- diers, travelling salesmen, tourists, and sometimes students fall into this group. Casual sexual behaviour is also related to basic changes in sexual norms and practices during the last decade, especially among young people. Some call it sexual permissive- ness, others sexual freedom; there also ap- pears to be an acceptance of homosexuality as an alternative form of sexual expression. Changes in sexual practices are further conditioned in many countries by the wides- pread use of the pill and other contraceptives which reduce the fear of pregnancy, by the exploitation of sex for advertising and com- mercial purposes, and by contemporary problems of drug abuse including alcohol. Studies have shown that people who have sexual intercourse with many different part- ners are often not aware of or are poorly informed about STD, the risks involved in catching or transmitting the infection, or about practical means of disease prevention. This leads to a second type of behaviour which is important in STD control: those who tend to select their sexual contacts casually could reduce their chances of infec- tion by using specific preventive measures. These include use of a condom by the male during sexual intercourse; genital hygiene before and after intercourse; and regular medical examinations to ascertain that they are not infected. The use of these simple pre- 20 Studies invariably show that most people are often not aware of or are poorly informed about sexually transmitted diseases, the risks involved in catching or transmitting the infec- tion, or the practical means available for dis- ease prevention. (Photo Len Sirman 0 ) ventive measures would drastically reduce the current amount of infection among those at risk. However, voluntary recourse to such mea- sures is subject to barriers. An important barrier is that many persons are inadequately informed about these basic and practical measures. Some people may not consider the infection serious enough to warrant the use of a condom, or soap and water on the geni- tals after intercourse, especially if they find these methods inconvenient or unpleasant. Use of the condom, for example, has decreased by 50 per cent since more conve- nient methods of contraception have become available even though these offer no protec- tion against STD. As for medical check-ups, people may find that STD services have an inconvenient location or time schedule, or that they are not very pleasant places to visit. The public health consequences of casual sexual contacts and neglect of preventive measures could be reduced if the people concerned were encouraged to seek early diagnosis and treatment in case of infection or exposure to infection. This is the third form of behaviour which is critical to STD control. Unfortunately, only a small number of those who are exposed to infection seek immediate medical attention. One reason for this attitude is that the infections may not produce signs and symptoms which cause a great deal of discomfort. For instance, wom- en with gonorrhoea may have no symptoms at all, and when they do occur the symptoms are usually slight. Furthermore, persons at risk should be able to recognize the symp- toms and be aware of the possible conse- quences of such infections. In many cases, however, sufficient information about what to look for and what complications to expect are lacking. Of particular importance is the fact that infection tends to induce feelings of shame and fear of public ostracism among those who are affected. Public attitudes are still too much based on the assumption that sexually transmitted diseases are afflictions peculiar to loose women and immoral men, and not to "decent" people. Even physicians and other members of the team who take care of STD patients may have similar attitudes, which explains the general reluctance of patients to visit physicians and clinics for diagnosis and treatment. 21 nothing to hide Considering these important social and psychological barriers which prevent people from consulting a physician, it is not surpris- ing that a large number of infected persons prefer to seek help and advice from unautho- rized persons or apply self-remedies or wait till the problem disappears. The fourth type of behaviour with an im- portant bearing on disease control is the degree to which patients cooperate with treatment. Since the patients contribute a more than average share of future infections, their willingness to cooperate with diagnosis and treatment, to indicate their sexual con- tacts, and to follow preventive measures aimed at avoiding reinfection is essential if they are to benefit from their previous deci- sion to seek early medical attention. Physicians have a special responsibility in this matter but are often ill-prepared to com- municate with patients on an objective basis and without passing moral judgement on their behaviour. The influence of doctors will depend to a large extent on whether they understand what it means for the patient to have one of these diseases, to take preven- tive measures or to come to the clinic. Too often physicians tend to view STD patients as socially marginal and inferior persons, which is in blatant contradiction with the facts. They are also insufficiently aware of the shame and social stigma that accompany sex- ually transmitted diseases. Patient cooperation also depends on the conditions of the place of treatment. Over- crowded premises, rushed procedures and health personnel who lack consideration and respect for patients create a negative image; this state of affairs clearly makes it difficult to obtain cooperation for follow-up visits or help in contact tracing. On the basis of the four types of behaviour described above, one can now better define the main educational problems in the preven- tion and control of sexually transmitted dis- eases. These can be stated as follows : How can we obtain a less casual selection of sexual partners among those who are sex- ually active? How can we persuade groups at risk to use preventive measures? How can we encourage persons who are exposed to infection to seek early diagnosis and treatment? How can we get patients to cooperate with treatment, including their assistance in locat- ing their sexual contacts ?- A short glance at the educational problems involved in controlling these diseases indi- cates the need to orient educational pro- grammes not only at problem groups such as STD patients, groups at risk, or the young, but also at all those who can and should be encouraged to create a more favourable cli- mate and conditions for sTD control in the community. This includes changing public attitudes, getting public support for control especially from legislators, politicians, health administrators, medical educators, teachers and parents so that they can talk about sex and disease with competence and without embarrassment, and orienting and adapting the services to the needs and particularities of the groups they serve. With this basic policy aim in mind, the main educational approaches to controlling such diseases can be viewed under the follow- ing headings. Informing the public Large-scale public information campaigns through the press, radio, television, films, publications and posters have been used in several countries, and are frequently selected as an approach to inform as many people as possible about how one becomes infected, what the signs and symptoms are and what to do about it. There is, however, a growing In a world where travel is commonplace, air- ports, railway stations, even the dining-car of a train, or a crowded beach, might offer conve- nient sites for posters offering factual advice about STD. ( Photo Len Sirman C ) consensus that widespread indiscriminate publicity of this nature is wasteful and inef- fective. It has been found that mass media are less well-suited to put across specific facts or to reach and motivate those who would benefit from prevention and medical care than, for instance, individual talks with parents, physicians and STD counsellors, or group discussions in schools, at work, or during special sm meetings. This does not mean that multimedia or large-scale programmes are useless. They have been used with great benefit to create an awareness among the general public and es- pecially among public leaders that such dis- eases pose a health threat to the community and that something should be done about it. For instance, support may be obtained for better treatment facilities, for introducing sex and disease education in schools, or for start- ing special education programmes for groups at risk. A public opinion that is well-in- formed and aware of the problem is less like- ly to retain negative judgement attitudes towards STD patients and their care. Large- scale programmes essentially provide the necessary impetus to take further and more specific initiatives in STD control. It should be added that the key to success of such campaigns has been the participation of in- terested public leaders from professional, political, religious, and youth organizations and the use of multidisciplinary teams with experts in public information. Large-scale information campaigns are also useful in publicizing the location and hours of locally available STD services. Tra- ditional methods include information notices in newspapers, public offices, lavatories, tele- phone directories and other places where people who need and want treatment are most likely to turn. In the United Kingdom an interesting method with a new approach is the Tele- phone Answering Service established in sev- eral cities. The caller hears a recorded mes- sage about the most common signs and symptoms, and a list of local clinics with their consultation hours. A live conversation is available too on another number for those seeking answers to more specific questions. The dialling number of this service is publi- cized in newspapers and on public transport. For groups at risk Several special groups would benefit from factual advice about STD including seamen, military personnel, professional entertainers, homosexuals, free living groups, migrant workers, tourists and the sexually active young. Their life-styles and attitudes about sex and disease are so different that each educational programme must be tailored specifically to their needs and must be car- ried out in places where they gather for work, leisure or medical care, and by people to whom they will listen. In a number of programmes, short films, slides or exhibits have been found useful for starting an open and guided discussion with questions and answers. Much depends on who initiates the sessions, where they are held and how well the programme leader can create an open climate for free discussion. Training of discussion leaders is usually help- ful and where possible more than one session should be planned. A growing number of such sessions are being held at schools, universities and youth centres. Places such as "You do so much with your mouth": a striking Swedish health education poster warns against diseases which can be contracted in this way. 22 gor sa mycket med din mun.

UWAGA MLODZI ! CHOROBY WENERYCZNE SZERZA WCZILONIF ROZ■0144..11. TO Strain. ,Rw•at 111..• 141 A W favC2144..o nothing to hide family planning centres, port clinics and recreational outlets for seamen, rural health centres and youth clinics have been relatively unexplored for getting education pro- grammes and counselling started. More at- tention should also be given to ways in which migrant workers can be reached at work or in their special communities, for instance through social workers. An interesting community programme which was set up in Madras, India, for STD control through education has been de- scribed on page 8 of this issue. The content and methods of the programme were based on discovering first what people in that area knew and felt about STD. Eventually the programme included training for health per- sonnel, STD information sessions for the staff, voluntary workers and local leaders, and discussions at hours convenient for the public. One of the conclusions of the Madras programme was that it takes time to change what people know and do about these dis- eases and that therefore educational efforts need to be continued for some time before their effect can be seen. Family first The family is by far and away the most important social milieu in which the attitudes and behaviour of children are moulded. However, it has to be admitted that in the area of sex information and sexual relation- ships many parents provide inadequate guid- ance to their children, either because they feel they do not know enough about the sub- ject or they do not know how to say it and when. Parents, therefore, need practical help in this area, but ways and means to do this have not been explored very thoroughly, ex- cept for a number of initiatives through adult education programmes or experimental parent-pupil learning groups. On the other hand it is generally recog- nized that the school has a responsibility in providing sex and STD education, but the existence and quality of such education varies from country to country. In some countries existing legislation may ban sex ed- ucation in schools, in others the introduction of the subject is only permitted in the late teens. Nevertheless some excellent pro- grammes exist in some parts of the world and these are based on a continuous and sequen- tial programme of explaining human growth and development, family life and sexual relationships including the risk of disease. Such programmes start at an early age, some- times at three or four, and continue till the end of schooling. They are given by teachers A Telephone Answering Service offering prac- tical information about STD has been estab- lished in several UK cities. Posters advertising the service are prominently displayed in public places. (Photo WHO) who are competent and feel comfortable with the subject, because it is quite unrealistic to expect untrained teachers in primary and secondary education to instruct and counsel students in sex and sexually transmitted dis- eases. Part of the educational programme for the young should therefore be devoted to selecting suitable teachers and providing training for them through workshops, in-ser- vice training sessions, or programmes in teacher training institutions. Good teachers as well as a continuous dia- logue between the school and the parents are essential. The teacher in charge of sex and STD education benefits from these contacts through a better knowledge of the student's family situation (divorce, adoption, alcohol- ism, etc.) and can reassure parents about what information is given to their children. Parents also benefit themselves from these contacts. Some of the material presented in A Polish health education poster symbolizing the biblical temptation of Eve, says: "Atten- tion youth! Venereal diseases are spreading. They can lead to disability or even death. Early diagnosis enables quick and definite cure. Both diagnosis and treatment are free and confidential at any dermatological clinic." school may be useful for their own education and may make it easier for them to talk freely with their children about topics such as sex- ual development, pregnancy, contraception, and sexually transmitted diseases. Besides the school, there is a large and mostly untapped reservoir of possibilities for educating and informing adolescents about such diseases, for instance through youth clubs or other social and health service or- ganizations. Such an alternative approach has been offered by the American Social Health Association, which provides guidance on how to organize and pursue "Venereal Disease Action Councils". Young volunteers of between 16 to 18 years of age receive a short course about all aspects of STD and its related aspects and are then put in charge of instructing the 13 to 15 year olds. A number of free clinics include sex and disease educa- tion and counselling as part of their health services for youth. Education at the clinic In many ways, the clinics where people who are exposed to infection come for treat- ment offer the most practical opportunity to explain to them how to take care of and prevent these diseases. Too little is known about the role played by doctors and nurses or social workers in this area. Because of the overcrowded conditions in many services, their lack of staff and deficiencies in handling patients resulting from inadequate education during basic training curricula, it seems that many patients leave the clinic without having received sufficient information about their problem during their visit. Booklets and pamphlets, or coloured illus- trations of male and female anatomy in con- sulting rooms, are little more than a panacea if there is no compassionate care in reason- able working conditions. There is no substi- tute for a doctor or any other competent person who does his best to understand the patient and takes time to explain how he can take care of his own health problem and protect the health of others. This may require a careful selection of staff and the provision of in-service training for all levels of person- nel at work in the clinic. In the long run, educating the patient real- ly starts with educating health practitioners specially to deal with sexual problems, of which STD may be but one example. A basic course in human sexuality during the train- ing of doctors, nurses and social workers, could help overcome the attitudes and inhibi- tions common to their culture and would equip them better to deal with their patients' sexually-related problems. In the past, several programmes of health education in STD control have met with variable success because they were often based on a short-term publicity approach, and lacked the necessary continuity and diversity in approaches and methods that one fortunately observes more and more among some current education programmes. Changing attitudes and misconceptions about sexually transmitted diseases, motivat- ing people to do things which may be incon- venient or awake shame and fear, and creat- ing the necessary conditions in society so that people can and will protect their health, is a long and difficult process, whose results may only be discernible over a long period. Nevertheless, in STD control as in other health matters, health education cannot be reduced merely to communicating facts since this would negate the reality of human beha- viour which lies at the core of the problem. ■ 25 treatment is available The development of antibiotics three decades ago gave medicine new weapons against STD but some diseases in turn developed new resistant strains BY R. R. WILLCOX M t is a modern paradox that the intro- duction of smpler and more effective treatments for the sexually transmitted diseases have been accompanied by ris- ing, rather than falling, case rates in every continent of the world. In the USA alone it is currently estimated that there may be nearly three million cases of gonorrhoea each year. This increase may in part be ex- plained by frequent symptomless infections, particularly in the female, and by the effects of technical progress and behavioural changes in modern society. Whatever the cause, effective and relatively simple methods of treatment are generally available today. Some of the common ones deserve to be better known among the public, in the light of the increasing incidence of these diseases. Diseases presenting as sores, spots or swellings: Syphilis: The first breakthrough in the treatment of this age-old and most serious sexually transmitted disease, which is caused by a corkscrew-shaped organism T. pallidum, was through Ehrlich's discovery of the arsen- ical compound "606" shortly before World War I. Previously for centuries mercury was given in the form of an ointment rubbed into the skin (inunction), by mouth or occasional- ly even by inhalation. This poisonous treat- ment risked causing such side-effects as in- flammation of the mouth with bad breath, loss of teeth and excessive salivation. The latter condition was believed to indicate the efficiency of the treatment, and jars in which the quantity of saliva was measured may be found in medical museums. The results of such treatment were poor and the distressing later complications of syphilis—sometimes extensive skin ulceration and tissue destruc- tion, bone involvement, mental deteriora- tion, madness, blindness, unsteadiness of gait, severe heart disease, "general paralysis of the insane" and eventually death—were by no means necessarily averted. Ehrlich's hopes of curing the disease with a single intravenous injection of arsphenamine were not fulfilled, and moreover it was a toxic drug. However with its improved suc- cessor, neo-arsphenamine, good cure rates were obtained if three or four courses each of ten weekly intravenous injections were given combined with simultaneous courses of bis- muth injections into the buttock. Allowing for a rest of one month between courses, the treatment lasted for a year. The results were good in those who completed it but many failed to do so either from default or because of toxic effects including jaundice, severe skin trouble, brain or other neurological damage or poisoning of the bone marrow from the arsenic and mouth inflammation or kidney damage from the bismuth. No wonder that there was excitement in 1942, when penicillin was shown by Mahoney and his colleagues at Staten Island, New York, to have cured four Norwegian sailors of syphilis in only eight days of treat- ment and to be free of such side-effects. Dis- covered by Alexander Fleming at St Mary's Hospital in London in 1929, it had been developed in the United States for its anti- biotic qualities with the treatment of wound infections in mind To maintain the necessary level of the drug in the bloodstream, injections of the early penicillins had to be given every three to four hours day and night and the patients were less appreciative of the new miracle drug than the doctors. However, with the intro- duction of repository penicillins able to be only slowly absorbed from the buttock, spaced injections became possible and today treatment is by means of 8 to 14 daily injec- tions of procaine penicillin or a smaller num- ber of weekly or twice-weekly injections of procaine penicillin in oil with aluminium monostearate (PAM) or benzathine penicil- lin. The results of treatment are excellent in the early stages of infection. The surface manifestations quickly disappear, the blood tests give negative results after a few months and no complications develop; indeed, by contrast with the earlier treatment, so effec- tive is penicillin that reinfection is quickly possible and not infrequently occurs. When treatment is given in the later stages the blood test may not become negative but complications are nevertheless prevented. However if these have already occurred, al- though the skin ulcerations rapidly heal, any damage already done to the aorta and heart or to the brain and nervous system cannot be made good even if the syphilitic process has been arrested. In all stages, however, penicillin given to an infected expectant mother will either pre- vent infection of the foetus or, if this has already occurred, will cure it in the womb. If penicillin is non-toxic, however, some persons are nevertheless allergic to it and it cannot then be used for fear of severe allergy Taming the treponeme. Scientists hope to dis- cover a simple skin test which would greatly facilitate syphilis diagnosis and control work. Here, in the United States, a research worker examines a test tube in which infected blood has been separated into blood cells and serum by centrifuge. ( Photo WHO/R. Phillips) 26 a •, • • • reaction—even death. If allergy is suspected, tetracycline or erythromycin tablets are given instead. Whatever the treatment, repeated follow-up checks are required for the ensuing two years. A vaccine has been produced against syphilis which is effective in rabbits if given intravenously twice weekly for some months. However, it produces undesirable side-ef- fects, and is not yet suitable even for testing in man. Soft sore (chancroid): Caused by a bacil- lus, this disease shows itself by multiple pain- ful genital ulcers with swellings and perhaps abscesses in the groin. At one time prevalent worldwide, it has now become uncommon in many countries following improvements in hygiene and washing facilities. In the last century drastic treatments involving cauter- ization or severe local caustics such as pure bromine were used. Today it usually re- sponds after one course or so of sulphona- mide or tetracycline tablets although some cases resistant to these substances have recently been reported. Herpes genitalis: In many countries this is the commonest cause of genital sore. Clus- ters of small blisters appear on the genitalia and are caused by Type II herpes virus, a close 'cousin' of Type I which causes cold sores around the mouth. Once acquired the virus is carried indefinitely and from time to time relapses may occur. The first attack tends to be more painful than those which follow. In the female the infection may be concealed internally on the neck of the womb and is under strong suspicion as the principal cause of the later development of cancer of the cervix. Unfortunately the drugs able to kill the virus are too toxic for use by injection except in very rare cases when the complications threaten life. One of these, 5 iododeoxyuri- dine (5 IDU), is given locally as are numer- ous soothing creams during the week while the sores heal. It is hoped that a vaccine will one day be available. Venereal warts: These are pink fleshy tumours also caused by a virus, which arise often weeks or months after exposure. Not as a rule serious, they are treated with local applications of podophyllin or by caustics although cauterization under local anaes- thetic may be required in obstinate cases. Some other sexually transmitted conditions not dealt with so far include lymphogranulo- ma venereum, more often found in tropical sea ports, which causes abscesses in the groin and rectal stricture in the female, and is treat- ed with tetracycline or sulphonamide tablets; granuloma inguinale—a rare disease but com- mon in Southern India and Papua New Guinea—which results in chronic genital ul- ceration and is treated with tetracycline or chloramphenicol by mouth or with strepto- mycin by injection; molluscum contagiosum, which causes scattered shiny red umbilicated spots and is treated by local caustics; pedicu- losis pubis (pubic lice or "crabs"), causing pubic irritation for which shaving the pubic hair and armpits is helpful and for which DDT lotion or powder or gamma benzene hexachloride lotion is used; and scabies, the cause of a very irritant skin rash, which is treated with application of a lotion of benzyl benzoate. Diseases presenting as genital discharges Gonorrhoea: The belief still persists, doubtless fostered by barrack room leg-pull- ing of new recruits by "old sweats", that red hot wires are inserted into the penis to cure gonorrhoea, the most commonly recognized sexually transmitted disease. This was never so, although a flame-sterilized wire loop is still often employed, when cool, painlessly to collect specimens of urethral pus—which is presumably the basis of this distortion. Less than 40 years ago the treatment of gonorrhoea in the male was by means of daily urethral washouts with a dilute solution of potassium permanganate while douches and antiseptic paints were used in the female. Men stood in line in the clinics awaiting their turn. Although the lucky ones apparently recovered after only one or two weeks, in others the infectious agent—the gonococ- cus—persisted for months. The average time of cure was 100 days and between a quarter and one-third of patients developed serious complications which might lead to urethral stricture, sterility, chronic pelvic invalidism in women, crippled joints and serious eye disease. Acute ocular infections, which were a frequent cause of blindness, were common- ly seen in babies newly born of infected mothers. The scene was transformed in 1936 by the introduction of the sulphonamides ("sulpha drugs") which promptly cured four patients out of five after only a week's course of tablets. Some cases, however, were due to gonococci resistant to these drugs and as the susceptible strains were removed by treat- ment the resistant strains gradually took over. This first became obvious in Italy in 1942 amongst the troops of both sides where the mass use of sulphonamides by prostitutes made them become virtual 'factories' of resistant germs. Within seven years the sul- phonamides were able to cure only a quarter of cases in the cities of Europe and elsewhere. Fortunately by this time penicillin had ar- rived, and as improved penicillin prepara- tions were formulated a cure of gonorrhoea in a single injection became possible. This method has been in common use for over 25 years. Nevertheless during this time strains of gonococci have emerged in certain regions which are less sensitive to penicillin. They may require a progressively increased dose up to 20 times the amount previously thought necessary, i.e. to around 5 million units, and even this amount unaided will of- ten fail in some areas of the world. The penicillin "line" is being held, howev- er, by the practice of giving two tablets of probenecid by mouth immediately or shortly before injecting the penicillin. This blocks the excretion of the antibiotic through the 28 .‘1 .ft.,■•■■•INMINI's: S ■••'.".„ A Scientific progress has made it possible to cul- tivate specific strains of treponeme. one sam- ple of which is being examined here by two scientists at the international research centre in Baltimore, USA (Photo WHO/ R. Phillips) A Isolating the patient in a barrel and applying questionable remedies was considered suitable treatment hundreds of years ago in Europe when syphilis was sometimes called the disease from Naples. Our etching shows that doctors fumigated the patient's clothes. ( Photo WHO) kidneys, thus providing a higher blood concentration (able to overcome the less sen- sitive strains) than would otherwise be the case, and there are few cases of gonorrhoea in the world today which will not respond to this regime. But the size of the dose is near the margin of what it is practicable to give in a single injection, particularly to patients of small stature. By giving the probenecid together with up to seven capsules of one of the newer penicil- lin compounds, an oral treatment using a single dose is also possible. Numerous other antibiotics and an improved sulphonamide which can be given by mouth in multiple dosage, and two which are given by single injection, are effective against gonorrhoea, but these may be too expensive for mass use in some countries. At present new discoveries are keeping pace with the deteriorating situa- tion, but this will not necessarily always be the case. Vaccines have already been tried to pre- vent gonorrhoea in man, so far without suc- cess. Recent striking results obtained in the use of vaccines against the meningococcus (one of the same family of organisms) in the current worldwide epidemics of meningitis will doubtless provide added stimulus to fur- ther research. Non-gonococcal urethritis: This condition, usually recognized only in the male, may have a number of causes but a member of a group of organisms called chlamydia can be found in many cases. It does not usually respond to penicillin and is treated by tetra- cycline tablets for one to three weeks. About one per cent of patients who appear to be inherently susceptible develop the more serious complication of Reiter's Syndrome— with arthritis involving a number of joints, backache and inflammation of the eyes— which may require hospitalization, some- times prolonged, and treatment with other drugs. Trichomoniasis: Caused by a protozoal parasite, this is generally the commonest cause of a vaginal discharge when com- plained of by the patient. It can also be car- ried by the male. Treatment is by means of tablets of metronidazole or nimorazole which can be given in single or multiple dos- age over one to seven days. It is advisable to treat the sexual partner. Candidiasis (thrush): This yeast-like fun- gus is another common cause of a vaginal discharge. It produces a cream-cheese-like discharge which adheres to the vagina and many patients complain of itching and sore- ness. Although it can be passed from the woman to the man causing external penile inflammation, in the female the question is not so much how it gets there (it being pre- sent in small amounts in throat, bowel and on the skin and elsewhere in many persons) as to why it grows when it does. The presence of sugar in the urine, pregnancy, the taking of antibiotics, or some states of debility may predispose individuals to this condition. There are no known drugs which can be given by injection or by mouth to eliminate the infection from the vagina (although tablets of the antibiotic nystatin may be swallowed to do so from the bowel). Treat- ment is by means of nystatin or other tablets, pessaries or creams inserted locally into the vagina over two to three weeks and the avoidance of tight fitting and nylon under- wear. Even so, relapses are not infrequent. If, as seems likely, the growing incidence of sexually transmitted diseases is caused even in part by the changing pattern of social behaviour and sexual mores in many regions of the world, these diseases will become still more prevalent in the coming years. The fact that women can be carriers of the infections without showing symptoms and without be- ing aware of them makes sexually transmit- ted diseases all the harder to check. The tide is unlikely to turn until a new generation of simple and effective treatment, capable of dealing with the most resistant strains, becomes available. ■ 29 counting the cost If the public realize that sexually transmitted diseases and their complications cost money, they may appreciate the value of more effective control BY R.C. RENDTORFF espite all that has been written and said in recent years about the cur- rent pandemic of gonorrhoea, sur- prisingly little attention has been paid to what it is costing society. The various sociological causes of the rapid increase of gonorrhoea in the United States and else- where, and the moral issues this problem raises, have been widely discussed. But the economic consequences of this disease upon the individual and society as a whole have generally been overlooked. However, in 1972, the Department of Community Medicine at the University of Tennessee in Memphis undertook research into the economic costs of the complications of gonorrhoea in women. The results of this study, extrapolated on a national basis, sug- gest that the total costs due to complications of this disease alone among women in the United States in that year amounted to some US$ 212 million. When the costs of various aspects of other sexually transmitted diseases are also taken into account, it is clear that, apart from being a health problem, sexually transmitted diseases are indeed of consider- able economic concern. Assessing the economic impact of gonorr- hoea essentially involves considering the complications of the disease in women. Acute gonococcal urethritis occurs in the male and recurs often enough but it generally yields rapidly to inexpensive antibiotic thera- py. For women the problem is entirely dif- ferent. In studying the disease, doctors generally think of the woman as the source of the male case, because she often has the disease without being aware of it. This is an impor- tant consideration for those attempting to control the disease. But those working in Phthirus pubis. A 1973 study of the louse problem in the United States, based on drug sales, suggested there were about three million cases and that approximately 30 per cent of pediculi- cides were used for the treatment of the sexually-transmitted crab louse. health departments who are responsible for controlling the current epidemic rarely come in contact with the individual patient suffer- ing from severe complications of the infec- tion. Such cases seek medical attention in the emergency room of the community hospital or from their private physicians. Unfortunately, private physicians often do not appreciate the magnitude of the problem in terms of controlling the infection in the community. The fact is that the economic impact of gonococcal infections in the com- munity is not fully appreciated. In addition, too few doctors realize the fundamental role that the gonococcus plays in the natural his- tory of pelvic inflammatory disease (PID), Bartholin's abscess, displaced pregnancy and disseminated gonococcal infection, including arthritis. H ospital survey The Memphis study was undertaken in an attempt to estimate the annual incidence of such conditions and their economic conse- quences, and was reported in the Journal of the American Venereal Disease Association. The City of Memphis Hospital, where the study was done, is a 1,000-bed complex serv- ing principally indigent people from a popu- lation of 750,000. The Memphis-Shelby County Health Department, where the city's only public STD clinic is operated, stands adjacent to the Hospital and essentially serves the same population group. In order to estimate the incidence of gonorrhoeal complications occurring in women, a survey was made of women who came to the Hospital's emergency room and data was collected for the equivalent of four one-week sample periods, each obtained dur- ing one of the four seasons of the year. A single observer made the clinical observa- tions, using strict criteria for acute PID and avoiding the double-counting of cases. This enabled an estimate to be made of the annual incidence of patients with acute PID result- ing from gonorrhoea who came to the emergency room. Annual estimates for It is still impossible to assess the huge cost of disease in most countries of the world. Here a patient is being carried bodily over difficult terrain to visit a mobile team doing a survey of communicable diseases, including sexually transmitted infections. (Photo WHO) 30

chronic PID and of other complications such as disseminated gonococcal infection, Bar- tholin's abscess and displaced pregnancy were made in comparable ways, depending upon the availability of case materials. Assessment of costs fell into three types. Direct costs consisted of personal and insti- tutional expenditure for hospitalization in- cluding medical services, supplies, drugs, transport and so forth. Indirect costs consist- ed of income lost through not working, down-payments which had to be forfeited and so on. The social costs included dollar figures computed for loss of school-days and homemaker's services (i.e. the value of a wife's and/or a mother's services). Such costs, of course, do not necessarily stop after the acute attack of the disease, and the study is following up each case so as to assess the costs of the chronic manifestations of those complications requiring medical manage- ment. The effect of this will be to increase the original estimates. The accompanying table shows how the estimated total may be separately attributed to the different disorders, or to different types of costs. The total cost of complica- tions of gonorrhoeal infections in women appearing at the City of Memphis Hospital in 1972 was $873,627. Hospital costs alone amounted to $581,248, and the second big- gest item on the list is the loss of homemak- er's services, amounting to over $ 200,000. The usefulness of the Memphis study lies in its potential to alert the community to the serious economic aspects of the disease, and to offer various government departments a more realistic basis for planning its control. Despite the risk of possible bias, the resulting figures were extrapolated from a local to a national scale. In order to do this, the num- ber of male cases of gonorrhoea at Memphis public clinics-7,598—had to be considered, since the disease in males usually produces symptoms sufficient for them to seek medical treatment. The reported number of male cases may be more reliable than the reported number of female cases, which are often symptom-free and therefore rarely reported to the health department. Since the number of male cases treated in the health department clinics reflects the amount of female gonorrhoea in the same socioeconomic population, the number of male cases in the city will be proportional to the costs of complications seen in females at the City of Memphis Hospital. This propor- tion in turn can be used to estimate the national costs of female complications by comparison with the nationwide total of male gonorrhoea cases, according to the fol- lowing equation : Human love and sex are as inseparable as this couple enjoying the privacy of a secluded beach. In many countries today there is less prudery and hypocrisy than ever before in his- tory. There is also a greater risk than ever before of a sexually transmitted infection. A huge task of public health education lies ahead. ( Photo WHO/E. Mandelmann) Costs of female complications National costs of at Memphis female complications Number of male cases at Memphis Thus $873,627 _ X 7,598 392,076 National male cases at public clinics X = $45,083,659 COST ESTIMATES OF COMPLICATIONS OF GONORRHOEA IN WOMEN AT CITY OF MEMPHIS HOSPITAL 1972 By disorder By type of cost Acute PID $579,490 Hospital costs $581,248 Chronic PID 165,501 Other direct costs 31,317 Disseminated gonococcal Indirect costs 51,452 infection including arthritis 38,468 Homemaker's services 201,152 Bartholin's adenitis 57,306 School-days lost 8,458 Displaced pregnancy 32,862 $873,627 $873,627 This estimate of over $45 million relates only to medically indigent women seen at public clinics and community hospitals. A national survey of STD treated by US physi- cians in 1968 showed that there was 3.7 times as much gonorrhoea treated in private prac- tice as in the public facilities. Using this factor, it was estimated that the private care costs for female complications of gonorrhoea in 1972 amounted to $ 166,809,530. Thus the total costs due to complications of gonorr- hoea in the female in the USA during 1972 amounted to $ 211,893,189. Similar extrapolations from the Memphis survey to the national scene suggest that hospital admissions for gonorrhoeal compli- cations totalled 175,000 in 1972 and hospital days amounted to 1,200,000: in other words, 3,200 patients were hospitalized each day, while there were probably more than 102,500 surgical procedures performed during the calendar year. Syphilis ranked third after chickenpox and gonorrhoea among reportable diseases in the United States in 1973, according to the US Public Health Service's Center for Disease Control, and a total of 90,609 cases in all stages were reported. Since the advent of adequate antibiotics, there has been a dra- matic drop in admissions for syphilitic psy- chosis, but the disease is still estimated to cost the US taxpayer $48,965,000 each year for the hospital maintenance of these patients. These figures do not, of course, include the cost of private medical care for the estimated 85,000 new cases of syphilis which occurred in 1973, nor is allowance made for the 500,000 untreated cases of all stages of syphi- lis believed to be present in the US popula- tion. While the appearance of penicillin and the concerted efforts to control syphilis have made inroads into the incidence of the dis- ease, syphilis obviously remains a problem and still entails considerable cost to the tax- paying public. An analysis made in 1968 of the economic benefits of a control pro- gramme which would actually eradicate syphilis suggested a potential saving of more than $3,100 million. Such so-called minor sexually transmitted diseases as chancroid, granuloma inguinale and lymphogranuloma venereum are becom- ing rare in the USA today—in 1973 there were only 1,338, 73 and 556 cases reported The Walter Chandler Clinical Services Cent- er, Memphis, Tennessee, where Professor Rendtorff undertook his research project into the cost to the public of STD. (Photo WHO) respectively—although some of their compli- cations might result in considerable costs in terms of medical and surgical management. However, there are other diseases minor only in the sense of complications but cer- tainly not minor in terms of their incidence and prevalence. Diseases such as trichomo- niasis and candidiasis in the female appear to be very common diseases. An insight into this problem on a national basis may be gained by analysing sales figures of drugs used to treat these infections. It is estimated that the cost of trichomonacides obtained from the National Therapeutic Drug Index and based on drugstore and hospital sales for the year 1973 amounted to $ 23,873,000. To judge by the list of manufacturers' prepara- tions used in the treatment of vaginal candi- diasis, there is a still larger market for such preparations, and many are compounded to deal with both infections simultaneously. A 1973 study of the louse problem in the United States, based on drug sales, suggested there were about three million cases and that approximately 30 per cent of pediculicides were used for the treatment of the crab louse, Phthirus pubis. This represents a sexually transmitted infestation, although we know that occasionally it may be transmitted in a non-sexual fashion. Assuming one $1.75 bot- tle to be sufficient for a single case, the total amount spent on the crab louse infestation in the USA in 1973 would be 30 per cent of 3,000,000 cases, or $1,575,000. There are a number of other STD agents but until their true role and their extent become better known it is difficult to assess their economic aspects. The costs of controlling these diseases, of course, are not chargeable to the costs of the disease, but they are real costs borne by the public. It is gratifying to see that federal and state expenditures allocated for sip control rose from $ 31,572,000 in 1971 to $ 48,230,000 in 1972. The epidemic of gonorrhoea appears to be directly respon- sible for the renewed federal and state in- terest in control efforts. Finally a word should be said about the cost of individual prophylaxis. It would be difficult to determine to what extent con- doms (sheaths) are used as prophylactics against STD as compared to their use in birth control. In the United States, where the pill is a commonly accepted method of con- traception, condom sales have not increased substantially in recent years. An analysis of drug store and hospital transactions in 1972 showed that sales of prophylactics amounted to $19,313,000. A public concern The control of STD has traditionally been approached through moralistic, social and emotional appeals to instil fear of the conse- quences of infection. Certainly the Memphis study has re-emphasized distinct hazards to women who acquire gonococcal infection, and the devastating consequences of this dis- ease deserve special emphasis. The public ought to know that gonorrhoea is dangerous and is costing them money. Control of such diseases is by necessity a public concern. If the public realized the expenses involved and appreciated that these can be brought down through expenditure of funds for control, perhaps more effective control would result. The magnitude of the problem of diseases transmitted through the sex act goes beyond the serious complications seen in gonorrhoea and syphilis. The high prevalence, as judged by the sale of drugs used in the treatment of trichomoniasis, candidiasis and crab lice, in- dicates that these so-called minor STD are minor perhaps only in clinical manifestations but indeed, like the common cold, are quite common and lead to accumulated costs of real magnitude. ■ 33 WORLD HEALTH QUIZ If you have read this issue of World Health carefully, you should have no difficulty in answering the following quiz. 1. Sexually transmitted diseases occur two to three times more frequently in the world's big cities than elsewhere : true or false? 2. In 1973, the notified cases of gonococcal infection in the United States numbered (a) 800,000 (b) 40,000 or (c) four million? 3. Halls Garden, the scene of a special STD education programme, is a district of (a) Bombay (b) Madras or (c) Calcutta? 4. Health education programmes, especially on a delicate subject such as sTD, require the active participation first of all of (a) doctors (b) schoolteachers or (c) com- munity leaders? 5. International tourism increases every year. Travellers who crossed national frontiers during 1973 totalled (a) 27 million (b) 95 million or (c) 215 million? 6. Everyone can now be vaccinated so as to avoid catching sexually transmitted diseases. True or false? 7. wHo is engaged in an international research project concerning certain sexually transmitted diseases in Africa. Is the project in (a) Senegal (b) South Africa or (c) Tanzania? 8. Use of a condom or sheath during sexual intercourse reduces the risk of sm infection. True or false? 9. For centuries, sufferers from syphilis received dangerous courses of treatment with (a) arsenic (b) prussic acid or (c) mercury? 10. Sulphonamides, or sulpha drugs, were introduced as a treatment for gonococcal infections in (a) 1921 (b) 1936 or (c) 1952? •(,--) t (3) '6 t 311-1I •8 t *L, osreA . 9 t (0) . g (0) . 17 (q) . E (v) .z . 1 : sJomsuy ast month, World Health described the work of the Village Health Worker, who plays a vital role in basic health care for the 75 per cent of the world's population who live in the countryside. Today we introduce another member of the health team... THE MEDICAL ASSISTANT Who is he? He or she is a health technician who has had eight or nine years of general education followed by technical training lasting two to three years. What are his duties? He must 1) take what steps he can to prevent disease and to promote health in his community; 2) be able to recognize the most common diseases; 3) treat simple ailments; 4) examine each patient and send any complicated cases to the nearest health centre or hospital. What is his exact title? In some countries these health workers are called medical assistants, in others feldshers, bedhars or Hakeem. There are other names such as health assistant, health technician, principal technical agent, health aide, public health medical deputy, assistant medical officer, or medical centre head nurse. (Replies to a WHO questionnaire included 10 different names for this, kind of worker.) What training does he get? He or she does not study medicine at, say, university level but instead has two or three years of practical training. He must be aware of his own limitations and understand that there are some things he cannot do. He may only act as an aide to a doctor, like the physician assistant in the USA, or he may carry out some of the functions of a doctor, like some feldshers in the USSR. There is a wide range of possibilities between these two extremes, depending on the circumstances. Where is he trained? As near as possible to the region where he will work. Is he paid a salary? Yes, usually by the country's health services. Who is his boss? The head of the health team or the doctor in charge at the nearest health centre. Can he look forward to promotion? Certainly, within the framework of the medical assistant's work. After some years of practical experience, he may be given the chance to specialize, as an administrator in the hospital or health service field, in training other health workers, as a psychiatric worker, and so on. He may also move up in his own chosen field: an assistant medical aide becomes a medical assistant, then a senior medical assistant, and eventually a chief medical assistant. In some countries, five to ten per cent of the young medical assistants may in certain circumstances be offered places in a Medical Faculty and start professional medical training. What are his working hours? They are very flexible. He has to be available at all times in case of emergency calls. 34 Authors of the Month Dr GEORGES CAUSSE is Chief of the Venereal Diseases and Treponematoses unit at vim headquarters in Geneva. Dr (Mrs) C. N. SOWMINI is Director and Professor at the Institute of Venereology, Madras Medical College, India. Professor Giovanni CALETTI is Director of the Dermat- ology Division of the Pro- vincial General Hospital at Mestre, Venice, Italy. Dr JEAN RIDET is Chief of the wHo project described on page 16. Dr ANDRE SIBOULET, a mem- ber of the wHo Expert Ad- visory Panel, is Chief of the Uro-genital Infections sec- tion at the Hopital Saint- Louis, Paris, and Director of the Centre for Urethritis at the Institut Alfred Fournier, Paris, France. Dr LUK G. VAN PARIJS iS Medical Consultant to l'Al- liance des Mutuelles chre- tiennes, Brussels, Belgium. Dr R. R. WILLcox, a mem- ber of the wno Expert Ad- visory Panel, is Consultant Venereologist at St Mary's Hospital, London, and at King Edward VII Hospital, Windsor, England. Professor R. C. RENDTORFF belongs to the Division of Health Care Sciences at the University of Tennessee, Memphis, USA. ORDER FORM Please enter my subscription to "World Health" as follows: US$* f* Sw.fr.* One year 8.75 3.75 25.- Two years 15.75 6.75 45.- Three years 9.— 60.— A is married to B. He also gets to know C. C has a boyfriend D, who still has a relationship . with E, who has had the misfortune to catch gonorrhoea from her new boyfriend F, who caught it from G, who caught it from her lodger H, who doesn't know who he caught it from. Then A returns to his wife B who becomes infected. Meanwhile, H has fallen head over heels for a lovely blonde, I, who then passes the infection on to J, who passes it on in turn to his lover K... You can see how easily one source can start a chain reaction. A recent survey carried out in the United Kingdom showed that 1,639 people had become infected from just one source. STD is dangerous Dont pass it on! (Adapted from a British Health Education Council cartoon film strip) WORLD HEALTH for readers everywhere One year: Two years: ❑ Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland mE ri nt ed in S w itz er la nd Im p ri Venus with Cupid and honeycomb, by Lucas Cranach