FIGURE 3.-Wartime Trends in Gonorrhea, Syphilis, Chancroid and Total VD
in the U. S. Navy

1944 JAN-JUN

demobilization to set out upon it. To be forewarned, however, is to be forearmed. There is no inevitable fate which dictates that we must continue along this path to ill health and social erosion. Before a plan of action can be determined upon, it is necessary to identify the problem clearly. Additional light is thrown upon it when the Navy rate trends by disease are examined. Again, comparison between the Navy trend as a whole and the United States is without compliment to the States. All-Navy curves are continuing downward, although they appear to be leveling off somewhat. The reduction in chancroidal incidence from 11.7 in 1940 to 0.75 for the first 6 months of 1944 is encouraging, especially in light of the increasing number of personnel overseas.

Current levels in the United States, when compared to 1940, also appear quite favorable. Gonorrhea and syphilis new admissions for the January-June period of 1944 stood 25 and 36 percent, respectively, below 1940. Chancroid has decreased by 83 percent. Since 1942, however, gonorrhea and syphilis have increased in the United States by 21 and 16 percent, while chancroid has continued down by 25 percent. The total venereal disease admissions have risen 24 percent since 1942. Incomplete data for July and August of this year indicate that these upward trends are continuing."

3 The author supplies this addendum as of Feb. 2, 1945: "The continental trend continued upward during the second half of 1944. The tentative new admission rate for the 11 months ending Nov. 30, 1944 was 30.4 per 1,000 per year. This represents an increase of about 36 percent over 1942, and of 24 percent over 1943."

The influences behind these developments are most difficult of assessment. Undoubtedly, one of the most important is the changing character of the total social scene. Only inadequately can we either describe or appreciate it. The pressures pulling and hauling at our young people in and out of the armed services are well beyond our comprehension, at least in emotional terms. That they are powerful, there is no doubt. The lengthening of the war, the increasing disruption of normal home life, the heightening transiency of our population, the experiences which the men and women of the services are undergoing,-all these and others too enter into the picture.

The sum effect may be termed promiscuity. But that is an almost indecent and certainly inaccurate description of the problem. One of its more important manifestations is found among service personnel returning from combat duty overseas, pockets full of money, and impelled by months on end of grueling, dangerous life without the benefit of a woman's smile. Something of the same end result may be observed among the 'teen age girls, although these tendencies are by no means limited to any one age group.

But we cannot consider the cause and effect relationship here as due solely and merely to current psychologic disorientations. The bulk of Navy men are young-35 percent are under 20 and 67 percent under 25 years of age. The younger groups are still in the formative stages of their habits; most of the group under 25 are still close enough to home ties to reflect rather directly their upbringing. Manifestly the Navy can do relatively little in any direct sense to correct such deficiencies, although without question the total impression of Naval service upon the new sailor or marine is one of positive orientation toward a high ethical standard, a spirit of cooperativeness and self-respect. In the long run, the social habits of the sailor represent a projection of his home, school, and church training. The current venereal disease situation would suggest that the word "failure" is not contraindicated with respect to such training.

Newer and more efficient modes of treatment may be presumed to have a considerable influence upon exposure patterns. It may be that the few Navy men who in the past have tended to conceal infection may now be reporting for Navy treatment in order to obtain penicillin therapy. It may be that better treatment has tended to minimize the dangers of venereal disease in the minds of some. This latter assumption is subject to grave question, however, on at least two grounds: (1) That by and large the informational level of most patients appears to be rather low, and the likelihood of appreciating the significance of new therapy thereby is relatively low, and (2) that to assume promiscuity is significantly affected by fear of disease is to fly in the face of psychologic truths and general experience, and is to underestimate the overwhelming importance of other factors in the exposure syndrome.

The influence of Negro venereal disease rates upon the total continental rate is subject to some differences of interpretation. Negro rates are substantially higher than white rates. As one

Navy venereal disease officer put it: "Rates are higher in men who lack a sense of security as to their place in life, in their unit, and in the Navy." In one Naval District the Negro complement, amounting to 2.8 percent of the total, accounted for about one quarter of all admissions. There can be little question that data such as these mirror the venereal disease treatment and case-finding situation among our Negro citizens and reflect as well upon general social and recreational provisions for Negro servicemen. "The American Dilemma" does not fail to leave its mark upon venereal disease control.

Among Navy venereal disease control officers the general impression exists that civilian venereal disease control and social protective activities have relaxed somewhat in intensity in the recent past. The general complacency which now plagues the war effort in these crucial phases of combat likewise leaves its impression on venereal disease control. In some areas there are already reports of increasing prostitution activity, although the pattern remains predominantly "amateur."

Recent attacks upon the basic concepts of venereal disease control education have not contributed to a better public understanding of the problem and the urgency of its solution.

Possible countermeasures appear to fall under three headings: control programs within the armed services, control programs within the civilian community and, linking the two, contact investigation.

There is little need to elaborate here upon the Navy control program except in very general terms. With respect to treatment, preliminary field experience has demonstrated the wisdom of authorizing general use of penicillin in the treatment of all gonorrhea and of early and latent syphilis, insofar as supplies of that drug are adequate locally to meet other, more urgent demands. Under controlled conditions a pilot field trial providing new information as to the efficiency of chemoprophylaxis has been undertaken. Among some 25,000 exposures a gonorrhea failure rate of 14 of 1 percent has been recorded. Education aiming at reduction of exposures and wider utilization of prophylaxis has been carried on since early 1944 along relatively new lines and directed primarily at the younger members of the Service who bulk so large in venereal disease reports. A more closely coordinated ArmyNavy-civilian attack on venereal disease, prostitution and related problems has been facilitated by the recent establishment of Joint Army-Navy Disciplinary Control Boards in each Naval District and Army Service Command.

Insofar as civilian control efforts are concerned, it is hardly the place of a Navy venereal disease control officer to turn to blueprinting. As seen from this angle, however, it is certain that the low level of venereal disease rates in general has been the result of aggressive public health control and social protective activities. More of this is needed today. The rapid treatment center development has proved a signal step forward, and would seem to loom ever more important in the treatment era ahead.

The prime task of all, both as a wartime measure and in future terms, is clearly that of case finding. We have now the weapons, the know-how, and a considerable degree of energy with which,

it is not too much to say, we could eradicate venereal disease as a major public health problem in a matter of years, if not of months. The key is case finding, the cutting into the reservoir of infection.

Case finding largely devolves into two elements, one relying upon the individual voluntarily coming to examination and treatment, the other upon locating possibly infected persons through contact operations. Voluntary reporting is basically a matter of public education, an honest education which brings to every individual the essential facts about venereal disease and its broad implications, with emphasis on the fact that it is a disease for which there is a cure. The time of eradication of venereal disease may very well be set by the degree to which we carry out this educational function, and the extent to which treatment facilities are available for rapid and efficient treatment.

Contact investigation, as the second basic element in case finding, has come into sharp focus in recent years by virtue of its inherent potentialities and by the development of large-scale contact referral systems by the Navy and Army. We have all approached this operation in a highly empirical manner, and with a concentration of attention upon those elements most significant to our practical needs. In the developing phase in which we now find ourselves, however, it would seem particularly desirable that some fundamentals be clarified, some assessment of responsibilities made, some energies expended to improving the procedures and actual operations.

Underlying any real progress in this field, however, is the necessity for some unity as to concepts and terminology. It is most difficult to discuss and solve common problems when the persons in the discussion are talking about similar though different things in different languages. It may be useful to dissect this contact operation to find out what it comprises and to provide some common ground for consideration.

One practicable analysis considers the contact operation under the term contact investigation. This embraces four progressive steps: (1) The contact-education interview where the patient is reorientated and reeducated with the objective both of inhibiting repeat infections and of obtaining pertinent contact information; (2) contact reporting, where the report form is forwarded to the appropriate agency for action; (3) contact location, where the alleged contact is searched for, and finally, (4) contact disposition, where the contact is examined and, if found infected, becomes a new patient and the process begins anew with a contact-education interview.

This nomenclature has proved useful in the development of a training program for Navy personnel handling contact reports and conducting contact-education interviews. Clarification of the broad concepts and terminology would do much to shift attention to the more immediately important operational areas.

One of the more important, from the point of view of the Navy, is that of contact-education interviewing. This and contact reporting are the primary responsibilities of the armed services in contact investigation. Conversely, contact location and disposition are the pressing problems for civilian agencies insofar as military contacts are concerned. Toward the improvement of interviewing,

the Navy is now engaged in development of a training plan which endeavors to transmit to large numbers of medical department personnel the basics of interviewing. Similar attention might well be given to field handling of contact reports by civilian health agencies.

This latter comment is prompted by Navy experience during the past 4 months with the new uniform system of venereal disease contact reporting. Conclusions can be only very tentative, but in general the acceptance of the system on the part of civilian and Navy medical personnel has been gratifying and successful. In but a few instances have indications reached us of failure to understand or to carry through obligations on the part of civilian agencies.

A random sampling of 1,000 of these new contact reports has been made which throws some light on the nature of our problem. The sample is reasonably representative, although it was taken from reports completed during the early days of the new system and is probably, therefore, somewhat below present levels of operation, both naval and civilian. The expected pattern-youth, pickups, home or hotel exposures, no prophylaxis-is found.

Of importance here, however, is the fact that an attempt is being made to evaluate such reports on an objective basis as to completeness of information and, indirectly at least, as to the efficiency of interviewing. One of the most meaningful evaluations is with respect to the degree of completeness of the contact's name, address, and place of employment.