The social environment / by Maggie Jones

The social environment The basic social conditions which have boosted the incidence of STDs are unlikely to change. So it is all the more important for countries to create suitable education programmes to deal with them 11 he so-called "permissive socie-ty" and sweeping changes in at-titudes to sexuality in the North , and increasing migration to the cities and the breakdown of traditional cul- tural patterns in the South , have led to an increase in sexually transmitted diseases almost everywhere in the world. Not only has the incidence of diseases increased; the number of dif- ferent diseases recognised has also risen . To the old trio of syphilis, gonorrhoea and chancroid have been added a "second generation " of STDs, including chlamydia , non- gonococcal urethritis , trichomonas vaginalis, herpes, genital warts and hepatitis. Now AIDS must be added to the list. The explosion of STDs in the cities of the Third World today is a reflec- tion of what happened in Europe fol- lowing the urbanisation which accom- panied the Industrial Revolution. By the turn of the 20th century , some 60,000 people were dying of syphilis every year in Britain. A serological survey taken in London in 1914 indi- cated that 14 per cent of men and seven per cent of women were suffer- ing from syphilis-and the rates for gonorrhoea were believed to be even higher . These kinds of level of STDs can be found elsewhere in the modern world. One recent survey in Ondo State, Nigeria, indicated that one in every four or five women had been infected by a sexually transmitted dis- ease. Other studies have estimated that some populations in Africa and Asia show prevalence rates of gonor- rhoea ranging from three per cent to over 18 per cent. 8 by Maggie Jones The advent of antibiotics and the provision of free confidential services for the diagnosis and treatment of people suffering from STDs helped to overcome these diseases in Europe and North America, and in developed countries syphilis has been declining ever since. However since the Second World War , and particularly in the 1960s, changes in attitudes towards sexuality and increasing sexual ex- perimentation outside marriage have led to a further increase in gonorrhoea and other sexually transmitted dis- eases in the developed world. In the United Kingdom, for exam- ple, the reported incidence of gonor- rhoea rose from 35,500 in 1962 to a peak of 66,000 in 1973. While much of the increase may have reflected the fact that more people were seeking treatment and thus increased the level of reporting of the disease , there is no doubt that the rise in incidence of the disease is genuine and is based on changing sexual behaviour. Since 1973, cases have fallen to 53,800 in 1984, and cases of gonorrhoea now form only one-tenth of the total number of STD cases reported annu- ally in the UK. However , this decrease of gonorrhoea cases is amply balanced by a continuous increase of non- Bar-girls in a South-East Asian city. Travel- lers, beware! Photo W HO/Zafar W oRLD HEALTH, November 1986 gonococcal urethritis which is now twice as frequent as gonorrhoea. In the United States, where it is more difficult to get accurate statistics because much treatment is private and goes unreported, reported gonorrhoea rates fell from their post-war peak during the late 1940s and 1950s but · then began to rise again after 1957, reaching an all-time high in the mid- to late 1970s of around a million cases a year; (because of under-reporting, the true annual figure is estimated at two million). The true incidence of STDs in the developing world is very difficult to discover. In some countries they are not reported at all. In others only the " traditional" STDs are reported, the remainder being ignored. Under-re- porting occurs everywhere , especially in those countries where STDs are mainly treated privately, rather than as part of a public health programme. All too often facilities for diagnosis and treatment are painfully inad- equate, and people rely on traditional remedies, most of which may be com- pletely ineffective. Further, in some societies women are reluctant to come forward to seek diagnosis and treat- ment, especially if women doctors are not available. The reasons for the increasing inci- dence and number of STDs are com- plex. The increasing drift of popula- tions into the big cities in all societies , changing marital patterns (with di- vorce becoming much more common) , and the tendency for people to enter sexual relationships at an early age and to have more sexual partners during their lifetime have all had their influence. The young are the most sexually active age group, and since the Second World War the proportion of young people in most countries has risen rapidly and is continuing to rise. Ac- cording to UN estimates , the number of young people aged 15 to 24 in Africa is expected to double by the year 2000, and in the Arab countries the 15 to 24 age group represents a fifth of the total. This is in direct contrast to the aging populations of the developed world , although those countries had their post-war "baby boom" which gave rise to a large population of young people in the W oRLD HEALTH, November 1986 Many parts of the world maintain strict norms for women's dress. Photo L. Sirman © 1960s and 1970s and has a bearing on changing sexual mores among the young. Increasingly, homosexual men, who may now feel more free to express their sexuality, have been infected with and have passed on STDs; the majority of cases of syphilis in the developed world now occur among male homosexuals. Homosexual men are particularly important in spreading STDs because of their promiscuity, which may be extreme in some cases. While Kinsey in 1948 found that the average homosexual man had three sexual partners in his lifetime, more recent studies have indicated that the average number is more than 50 , and in some populations it is much higher than this. Homosexual men are also at particular risk of contracting other sexually transmitted diseases, includ- ing AIDS and such bowel infections as giardiasis. Easy access to contraceptive methods and the removal of fear of pregnancy have had a powerful effect on sexual freedom . Changes in the use of contraceptive methods may have had their impact too. Barrier methods, particularly the condom, are known to protect against STDs, whereas in- creasing use of the contraceptive pill and the intra-uterine device (IUD) instead of barrier methods may have increased the number of disease complications. Increasing urbanisation in the Third World has had a powerful effect on attitudes to sexuality and sexual behaviour . Increasing populations m 9 many farming areas have led to short- er fallow periods for the land , lower yields and smaller family plots , with the result that young men move to the cities in search of work , leaving behind the traditional villages and way of life. In a village everyone knows every- one else; it is very difficult to keep an extra-marital affair a secret; and the traditional culture had strong sanc- tions against such behaviour. But when people go to the cities they leave behind such constraints and frequently experience loneliness and disorienta- tion ; they are also bombarded by sophisticated films, literature and ad- vertising all of which tend to promote free sexual activity . In these circum- stances sexual experimentation, whether heterosexual or homosexual , is likely to be on the increase. The traditional morality is being challenged by the young throughout the Third World , especially where it seems inappropriate to the conditions in which people are now living. Mar- riage at a young age and arranged marriages become less popular in the face of imported ideas of romantic love-alas , too often tarnished by reality-and increasing freedom to mix with other young people . Women in- creasingly seek educational oppor- tunities which offer them an alterna- tive to youthful marriage and parent- hood , and these women are then more likely to enter sexual relationships outside of marriage . Young men, lack- ing in guidance or experience, may view the young women in their age group as " fair game" if they are not going to marry them , and are unlikely to take precautions either against con- ception or against the risk of sexually transmitted diseases. The huge increase in migrant labour throughout the world , opened up by easier travel and by labour shortages in some countries or meagre employ- ment prospects in others, has meant that large numbers of men are going abroad to work-an estimated four million migrant workers in Europe alone. These are usually unattached men who, until they have settled into the new cultural background and liv- The permissive society: boy meets girl in a European park. Photo WHOfT. Urban W oRLD HEALTH, November 1986 Discreet veils for the women in the Eastern Mediterranean. Photo L. Sirman © ing situation and formed stable rela- tionships, are at risk of acquiring STDs through casual sexual encounters. Men working temporarily away from home in distant cities on engineering projects are also at risk of contracting STDs and passing them on to their wives or others in their communities when they return home. The increasing ease and cheapness of air travel for tourism means that STDs can be spread from one region to another, and new kinds of infection can be brought to distant countries. Casual sexual relationships are not uncommon on foreign holidays, espe- cially in cities which notoriously make money out of sexual entertainment. Attitudes towards STDs affect people's willingness to seek treat- ment if they suspect they are infected, and so of course does the availability of suitable health services. In most African countries , only 30 to 35 per cent of people are reached by modern health services, which are situated W oRLD HEALTH , November 1986 mainly in the cities. Furthermore, peo- ple suffering from STDs do not like the reason for their visit to be iden- tified: rather than special clinics, STD diagnosis and treatment in a general health care facility may be much more appealing . Young people in particular may be afraid of going forward for treatment , in case their parents find out, and women tend to feel embarras- sed and ashamed. For some young- sters, however, there is no problem: gonorrhoea is viewed as a "man's disease ," and you're not a real man until you've caught it! Education is a key factor in helping to persuade people to seek treatment -keeping them informed of what the diseases are and the consequences of not having treatment. Unfortunately, since the advent of penicillin-resistant strains of gonorrhoea isolated in West Africa and the Philippines in 1976, and with the new generation of dis- eases, some of them viral , which are less easy to treat, some of the impetus may have gone out of seeking treat- ment. Where people feel that their condition is unlikely to respond to medical treatment , they are more likely to neglect it or use traditional herbal remedies , sometimes with devastating consequences. In most Third World countries , anti- biotics are available over the counter at pharmacies or even in general stores and market stalls. People who realise or suspect they are infected with an STD may take the wrong or incom- plete dosage, which will fail to clear up the infection and , worse, will promote the transmission of antibiotic-resistant strains. Where the diseases are understood and treatment is freely and confiden- tially given, the problem is not a major one. There are many areas throughout the world, however, where people not only know very little about STDs and how they are transmitted, but do not know where they can turn to for advice and effective treatment, or are ashamed of doing so. The underlying social conditions which have led to the rise in STDs throughout the world are unlikely to change in the short-term. So it is all the more important for countries to stop ignoring the problem but to accept that the STDs are a fact of life , and to create appropriate edu- cational and health programmes to deal with them. • 11