VENEREAL DISEASE CONTROL

By A. J. ASELMEYER, Surgeon, United States Public Health Service

RECOMMENDATIONS FOR IMMEDIATE CHANGES AND IMPROVEMENT

It is recommended

1. That a change be effected in the organization of the District of Columbia Health Department relative to the administration of venereal disease control. A separate division or a subdivision with a high degree of autonomy should be organized with a full-time officer to direct the venereal disease control program.

2. That a local advisory committee to the health department be organized under the leadership of a full-time venereal disease control officer, the membership of this committee to include representatives from medical and allied professions and voluntary social and treatment agencies.

3. That clinic service be augmented so as to make available facilities for (a) the diagnosis and emergency treatment of any patient who applies; (b) any person who is referred by a private physician either for continued treatment or for consultative advice or opinion; and (c) any patient who is unable to afford private medical care.

4. That a patient clearing house be established. The functions of this organization would be (a) to maintain records to serve as a means of preventing duplication of follow-up and to avoid unnecessary and sometimes dangerous duplication of medical service, and (b) to secure for transients, transferred or incompletely treated patients, a statement or complete record of previous treatment as a factor in promoting the continuity of therapy.

5. That upon request there be free distribution of antisyphilitic drugs by the department of health to all persons administering treatment. The drugs offered should include at least two of the arsenicals and a generally accepted bismuth or mercury preparation.

6. That greater emphasis be given the early detection and adequate treatment of syphilis in the pregnant woman.

7. That provision be made for better epidemiologic work for the early infectious case.

8. That the physicians, clinics, and institutions treating venereal diseases cooperate with the health department by furnishing complete morbidity and mortality reports on venereal diseases.

9. That the health department laboratory continue to take advantage of the annual service extended by the U. S. Public Health Service for comparative examination of serodiagnostic tests for syphilis and subsequently offer a similar opportunity to private laboratories in the District of Columbia.

10. That a comprehensive survey of all medical sources of treatment be instituted as early as possible to determine the extent of the venereal disease problem in the District of Columbia.

ORGANIZATION

Administration.-The control of venereal diseases is a function of the health department, at present attached to the bureau of preventable diseases. There is not a full-time venereal disease control officer. Legal provisions.—A comprehensive law for the prevention of

venereal diseases was passed in February 1935 (Pub. 494, 68th Congress).

Scope of activities.-The program of the bureau of preventable diseases of the District of Columbia Health Department in the control of venereal diseases is as follows:

1. To obtain morbidity and mortality reports of venereal diseases. 2. To provide treatment for indigent patients with syphilis, gonorrhea, and chancroid.

3. To render free laboratory service for diagnostic and treatment control for venereal diseases.

Personnel and expenditures.-The personnel and expenditures required for operating the venereal disease clinics in 1938 are shown in detail in table 1.

TABLE 1.—Personnel and expenditures for venereal disease clinics in the District of Columbia

The funds allotted for venereal disease control work in the District of Columbia for 1938 were $22,050, or a per capita amount of $0.035. This amount is only 35 percent of the recommended standard of the American Public Health Association. Low per capita allowances for contagious disease control, tuberculosis control, and maternal and child welfare also are found in the budget for the District Health Department. However, the rate for venereal diseases is proportionately lower than that for any of the other three mentioned.

Table 2 shows the total yearly expenditures for the health department venereal disease clinics from 1927 to 1938, the per capita costs, and the number of personnel assigned to this activity.

TABLE 2.-Annual personnel and per capita expenditures for venereal-disease control in the District of Columbia from 1927 to 1938

In table 2 it will be noted that there has been a steady increase in the per capita allotments for the conduct of the health department's venereal disease clinic. However, the ratio of work performed to the expenditures indicates that the increased cost has been disproportionate to the amount of work accomplished (table 3).

TABLE 3.—Number of visits to venereal-disease clinics and total expenditures by years from 1926 to 1937 in the District of Columbia, with percentage increases in relation to those of 1926

During the 11-year period, 1926 to 1937, the number of visits increased 448 percent, whereas the amount of the budget for the clinic increased only 134 percent. On a basis of physician hours to patient visits to the clinic it was found that only 2.6 minutes of a physician's time per visit is devoted to the patient.

MORBIDITY AND MORTALITY

Morbidity. The present venereal disease law requires every medical source to report the treatment of all patients with venereal disease to the Department of Health of the District of Columbia. The private physicians of the District of Columbia reported 27 percent of the cases reported from all sources.

The ratio between reported cases and those actually under observation and treatment determined by the 1-day census method indicates that reported rates for venereal diseases are usually not more than one-half of the actual rates in a given community.

A comprehensive survey of all treatment sources of venereal diseases has not been made for the District of Columbia. However, in those communities of a similar social and economic makeup a prevalence rate for venereal diseases based on census surveys gives a prevalence rate quite similar to that found from reported cases in the District.

Table 4 gives the rates per 1,000 population of those reported as being under treatment. The prevalence rate in 1936 for syphilis was 8.4 and for gonorrhea 6.2. A 1-day census survey of venereal diseases in Baltimore gave the prevalence rate for syphilis as 9.3 and for gonorrhea 4 per 1,000 population.

TABLE 4.-Cases of venereal disease under treatment by all medical sources reported to the Department of Health of the District of Columbia in the years 1934, 1935, and 1936

If reporting is as incomplete in the District of Columbia as elsewhere in the Nation, the magnitude of the venereal disease problem based on those cases reported is greater than the average. In the light of this possibility it would appear highly desirable to determine the extent of the problem by means of a survey of every treatment source of venereal disease in the District of Columbia.

Mortality.-Deaths reported to the District Department of Health which result directly or indirectly from syphilis per 100,000 population are about constant over the 3-year period, 1933-35. The average rate is approximately 27 per 100,000 population. The largest proportion of deaths from syphilis is not reported by the specific manifestation of the disease.

TABLE 5.-Deaths and death rate per 100,000 population from syphilis, tabes dorsalis, and general paralysis of the insane in the District of Columbia, 1933, 1934, and 1935

The majority of treatments for venereal diseases are provided by the District Department of Health at the social hygiene clinic at 512 I Street NW. Since August 1, 1937, antisyphilitic treatments for women and children have been provided at the child welfare centers located at 230 Third Street NW., 301 G Street SW., Freedmen's Hospital at Sixth and Bryant Streets NW., 5009 Grant Street NE. (Deanwood), and the Giddings School at Third and G Streets SE.

Quarters and equipment.-The clinic at 512 I Street NW. consists of a waiting room on the first floor which, during the heavy sessions, cannot accommodate the patients. There are three adjoining rooms, one for taking histories and interviewing patients, one for the nurses, and a room which serves as an office for the chief of the clinic.

The treatment and examination rooms are on the second floor. The room for administration of arsphenamine is 15 by 19 feet in area; that for hip treatments and for the passage of sounds, massage, etc., in gonorrhea patients is 12 by 12 feet; that for the irrigation of male patients with gonorrhea, 11 by 21 feet, with six irrigation outfits, sterilizers, and sink; and that for the examination of new patients, taking of smears, and making darkfields, 11 by 12 feet. There are also two small rooms for the treatment of gonorrhea in women, including cauterization, one small room used for dressing by women patients. The social service department has two small rooms in the basement for conducting interviews and keeping records.

No space is available for adequate physical examinations of patients.

Laboratory.-Smears on male patients with gonorrhea and darkfield examinations on suspicious lesions are done in the clinic. The microscope and darkfield attachments are ample. Approximately 50 darkfield examinations have been made during the past 3 months, all of which were negative. Urinalyses are made as a routine measure on all patients treated for syphilis. Smears on female gonorrhea patients are sent to the department of health for laboratory examination.