Are We Checking the Great Plague?
Are We Checking the Great Plague?
by R. A. VONDERLEHR, MD., An Article in Survey Graphic, April, 1940
Editor’s Note: R. A. VONDERLEHR, MD. was an Assistant Surgeon General of the U.S Public Health Service who was later appointed Director of the Centers for Disease Control and Prevention (1942-1951).
A LITTLE LESS THAN FOUR YEARS AGO SURGEON GENERAL Thomas Parran launched the present campaign against syphilis. The knowledge and prestige of the United States Public Health Service were pitted against the pallid spirochete. The battle has since been waged continuously with the cooperation of the medical profession, health officers, and voluntary agencies all over the country. It is of interest to pause briefly and take stock.
In 1936, slightly more than 500,000 people infected with syphilis sought treatment. Another half million were infected but failed to take treatment. It was also estimated that syphilis struck one out of ten adults at some time in life.
With the acute communicable diseases, information as to the trend of an epidemic is accumulated rapidly. Not so with insidious syphilis. Keeping live and accurate records for all the syphilitic patients of the nation is a big problem. But the most modern mechanical accounting system is being applied to the task.
Reports obtained from this system during the last year and a half show that the percentage of patients with early syphilis seeking treatment increased by about 25 percent. And these reports are from representative parts of the country.
From this meager information it appears that we are beginning to learn the facts. In every other country which has been successful in controlling syphilis there has been an increase in the number of patients with early syphilis under treatment during the first few years of the campaign before a decline in the attack rate began. Paradoxically, the increase in patients with early syphilis in the United States during the last few years is good evidence that the disease is beginning to be controlled. It shows that we are getting treatment into the large syphilitic patient load which formerly did not seek treatment at once.
There is more concrete evidence of progress in another form. Facilities for the diagnosis and treatment of syphilis are being increased and expanded all over the country. Blood tests constitute the most important diagnostic measure in syphilis. The number of blood tests performed in state owned or subsidized laboratories rose from 2,400,000 in 1936 to 4,500,000 in 1938, and to 6,200,000 in 1939. While some of these blood tests were done to determine the patient’s progress under treatment, such a phenomenal increase shows that hundreds of thousands more people are now being examined for syphilis than formerly.
The reader may be totally unfamiliar with the technical details of syphilis control, but he must be aware by now of the importance of treatment. It is in the application of control measures that the most striking advance has been made. Almost 40 percent more doses of the arsenical preparations used for syphilis were sold in 1938, the last calendar year for which figures are available, than in 1936. There is a record of about 800 free, pay, or part-pay venereal disease clinics in the United States three years ago. but today there are more than 2400 treatment centers. In 1936, there were 3,350,000 treatments given in these centers, and 64,000 patients were discharged as arrested or cured. In 1939, clinic treatments numbered 8,000,000, and 103,000 patients were discharged as arrested or cured.
I do not wish to give the impression that present day diagnostic and treatment facilities are adequate. Indeed. they arc only about one fourth to one third effective, and there is no uniformly high level of efficiency. There are many excellent treatment centers operated by governmental and private agencies, such as the municipal clinics in New York and Chicago, and the Slossfield Community Center at Birmingham, Ala. Far too many poor ones exist, however, such as the municipal clinic in a southeastern town of 15,000 population, the main entrance to which can be gained only by waiting half a block through an alley. Perhaps it is more than a coincidence that this southeastern town also tolerates a proportionately large segregated area in its suburbs. The fronts of some of the houses in this district have electrical signs advertising the “profession” of the occupants. For the less imaginative prospective customers, one or two of these signs are definitely pornographic.
Costs and Services
ONE OF THE MEMBERS OF THE APPROPRIATIONS Committee of the House of Representatives, in commenting on a venereal disease control appropriation for the Public Health Service in the first session of the 76th Congress, expressed the opinion that the money should get “down into the diggings.” This gentleman aptly expressed the slogan of the campaign. I would modify his statement as follows:
Transform money to service and get service down into the diggings The program has now reached a significant point in terms of the development of service. Every executive knows that an effective administrative organization is necessary to govern a comprehensive business or scientific project. Yet the venereal disease control administrative costs within the Public Health Service have not exceeded 2 percent of the funds available. And administrative work within the states costs only slightly in excess of 1.5 percent more.
I discuss this detail only because I wish to emphasize that today a solid administrative foundation exists upon which an economic and effective control program may be built. Because of these carefully laid plans it is logical to believe that the venereal disease control power of the dollar will expand as the program gains momentum. For instance, in one area which was surveyed recently, it was found that $3 spent during the second year of the campaign purchased treatment services which would have cost $5 during the first year. Similar economy is possible throughout the nation.
One of the important problems is the development of a uniform, nationwide program embracing all of the generally accepted and fundamental principles. In developing this uniform program, the diverse social and economic conditions within the states must be kept in mind. The Public Health Service has no authority within the state, and even federal funds under the law become state money when the disbursement is made to the state treasury. The national program, therefore, is being adroitly developed on a persuasive and advisory basis.
To help make the work consistent in the 63 various parts of the country, state and territorial health officers in conference with the surgeon general have set up minimal standards, the adoption of which is required by all health departments receiving a federal allotment. Such standards include:
1. Demonstrated efficiency in the performance of blood tests by all subsidized laboratories.
2. Laboratory services made available as freely for the venereal diseases as for all other communicable diseases.
3. Free emergency treatment for all patients in the critical stages when syphilis and gonorrhea are highly infectious, and free routine treatment of all patients who are referred by a physician or are known to be unable to pay for private
4. Free anti-syphilitic drugs to all physicians authorized by law to treat syphilis.
5. Treatment available to all infected people on an equal basis, whether residents of the governmental unit or not.
6. Due consideration by state health departments to the reallotment of funds to ban areas, where the venereal disease problem is usually more serious.
7. A full time venereal disease control medical officer to head the campaign in all states or cities with a population in excess half a million.
Practically all of these standards have been adopted by every state. These requirements, however, represent only the framework of a complete control program. In consequence, demonstrations have been set up in selected areas where the problem is acute and where there more than average interest in the work. Federal financial and technical assistance is provided for a limited number of years in these demonstration areas with the understanding that the local and state authorities will take over the model program when federal assistance stops.
One of the first such demonstrations was launched in Camden, Glynn and McIntosh Counties, Georgia. Special aid was given by the Public Health Service for a local campaign embracing the most modern principles of venereal disease control, and the project was developed with the assistance and cooperation of the Georgia State Department of Health, and aided and directed by the local earth department. It is in this region that the “bad blood was wagon,” so vividly and interestingly described by Walter Davenport in Collier’s recently, was given its initial trial.
Clinics On Wheels
Experience WITH THIS MOBILE TREATMENT UNIT IN Southeast Georgia has led to the adoption of similar units in seven other southern states. It has been proven that such unit doubles or trebles the number of patients to whom clinic team can administer treatment in rural areas where the prevalence of syphilis is high. And this greater am efficiency is accomplished at a cost of only one fourth of the total salaries of the personnel serving on the unit.
Among a dozen or more demonstrations, two or three are noteworthy. In Albuquerque and Bernalillo County New Mexico, a public spirited citizen, aided with money raised by the Junior League through subscription dances and card parties, donated a sufficient sum to start a syphilis clinic. The local health officer, a serious-minded young physician, was deeply interested in the control of the venereal diseases and convinced the county commissioners that real economy was to be found in this kind of health work. The Public Health Service, in searching the Rocky Mountain states for a spot where a field study might be fruitfully conducted, learned of the work in Albuquerque. With relatively nominal aid from the state and from the federal government, it was possible to establish a complete modern program in this part of New Mexico.
Coal mining districts and oil fields are areas where syphilis is an unusually serious problem. The coal fields of West Virginia proved to be no exception. Logan County was interested in syphilis control and a model program was organized there. The West Virginia State Department of Health aided. Previous to setting up the demonstration, search for the germ of syphilis in the primary sore had not been done because the special microscope necessary was not available, nor was case finding carried out. Both of these procedures are of basic importance in the finding of patients with early infectious syphilis. Their application in Logan County resulted in the detection of a serious epidemic, which for a short while was of alarming proportions and involved dozens of the young men and young women in the community.
In Chicago an intensive system of finding and treating syphilis has been set up by that veteran, O. C. Wenger, a hero of Paul de Kruif’s “The Fight for Life.” Under the direction of this energetic officer of the Public Health Service, hundreds of thousands of Chicago’s citizens have had blood tests, and treatment of those found to be infected has been arranged. The private physicians in Chicago have profited by this work, for many syphilitic patients have been sent to them for thorough examination and treatment, if necessary, after the routine blood testing. Infected people who cannot pay for private treatment have been referred to an enlarged and greatly improved municipal clinic.
Clinical research has been intensified and extended Such experts in syphilology as Cole, Moore, O’Leary and Stokes have combined the talents of the workers in the excellent clinics at Western Reserve, Johns Hopkins, Mayo Clinic, and the University of Pennsylvania with federal assistance and administrative guidance. Exhaustive studies are under way to find more practical methods of treatment, to solve the complex problems of the communicability of syphilis and its conjugal transmission, and to determine the significance of negative findings for syphilis in infants born of syphilitic parents.
Parenthetically, prominent urologists are also engaged in a group study of gonorrhea. Barnes of the College of Medical Evangelists, Clark of Oklahoma City, Cox of Boston, Deakin of Washington University Medical School, and Pelouze of the University of Pennsylvania are diligently working together to discover the true value of the new sulfanilamide compounds for the treatment of gonococcal infections in male patients. Indeed, it may even be that control of gonorrhea through the use of these newer chemotherapeutic preparations will be attained before the more insidious syphilis is checked.
Laboratory work carried on under the direct auspices of Public Health Service workers should also be mentioned. In this field are studies of a new group of anti-syphilitic drugs known as the arsenoxides, improvements in serologic blood test technique, investigations of the efficacy of numerous prophylactic agents, and researches in the course of the sulfanilamide’s action on gonorrhea in women.
Information Plus Legislation
ESPECIALLY PRAISEWORTHY IS THE EDUCATIONAL work which has been done to acquaint the public with the facts about the venereal diseases. Recognition was recently given to the diligent workers in this field in the magazine Time. New educational material has been prepared and old revised with utility and economy uppermost in mind. More than a million popular Public Health Service penny folders have been sold by the Government Printing Office and distributed by health departments and private physicians. The American Social Hygiene Association and other unofficial agencies have aided greatly in educational work.
A small monthly medical journal published by the Public Health Service has been improved and revised. This periodical, known as Venereal Disease Information, has an established reputation. For many years it has had the largest paid subscription list of any of the publications of the national government.
Federal assistance has been available to the states only when the social security law was enacted, except for a short period toward the end of and just after the World War. The most helpful law for the control of syphilis up the present time is the LaFollette-Bulwinkle act of May 24, 1938. This law amended the basic act of July 9, 1918, and provided special funds for support of the program in the states. Five million dollars was appropriated for the fiscal year ending June 30, 1940, and $7,000,000 is authorized for the year beginning July 1, 1940 These funds are allotted on the basis of: extent of the venereal ease problem; the financial need; and the population. he first two allotment methods permit the utilization the appropriation as an equalization fund in the poorer states and where the syphilis problem is greatest.
Specific appropriations by the states and by local governments have been most encouraging. Very reasonable etching requirements must be met to obtain federal money. To get this year’s share ($4,350,000) of the federal appropriation, the states must raise a total of $3,450,000, either from old or new state or local appropriations. But re state and local health departments have actually budgeted for this fiscal year a total of slightly more than $7,000,000 as matching credits against the total allotments from the Public Health Service of $4,350,000, or more an twice as much as is required.
In the States
A BRIEF ANALYSIS OF SOME OF THE STATE AND LOCAL appropriations is interesting. Most areas are meeting their responsibilities in a reasonable way, as would be assumed from the total sums just cited. State and local funds made available in some instances are liberal indeed when the fund-raising potentialities of the respective governmental nits are considered. In a few instances there is definite evidence that the state legislature, the city fathers, or the young commissioner prefer not to accept their responsibility . Thus, Mississippi makes available $126,000, while comparatively wealthy central state of twice the population has raised only $102,000, of which about $75,000 comes from one of its two big cities. South Carolina has put up $102,000 as its share, including a new $30,000 state appropriation, but a very affluent eastern state with five times the number of people barely reaches the $1)0,000 ark. Wealthy California has raised $375,000 by appropriating $200,000 new money, but one of the wealthiest and equally large southern states with a high incidence of syphilis appropriated only $185,000.
Nineteen states have passed a law in the past three years requiring a premarital examination, including a blood test on prospective bride and groom. Connecticut was the first state to adopt a premarital law based on modern principles of control. In 1936, the year the law was placed on the statute books, thirty-eight patients with congenital syphilis were reported. In 1937, there were twenty-four reported cases; in 1938, sixteen; and, in the first six months of 1939, seven patients. Thus, in three years there was a education of more than 50 percent in the number of reported patients with congenital syphilis.
I know of no tragedy so great as the transmission of syphilis to the innocent, and particularly to the unborn child. We have had the means necessary to prevent congenital syphilis for thirty years; but because they have not been used, this stage of syphilis is still ten times as common as infantile paralysis. We know little or nothing of the transmission of infantile paralysis. We do know how syphilis is transmitted from expectant mother to unborn child. In spite of this, we, as human beings, have not had the common decency to do more than make a beginning in our attack against syphilis in the unborn. If premarital laws will prevent only a small fraction of this plague—and it is my opinion that they will prevent the greater portion—they would be well worth a trial.
Since 1936, seventeen states have enacted laws requiring a blood test for syphilis as part of the expectant mother’s prenatal examination. Such legislation constitutes a sound line of defense and insures proper treatment which, if begun before the fifth month of gestation, will secure a healthy baby for ten syphilitic women out of eleven. Unfortunately, there are still obstetricians who insist that their patients are in such an exclusive class that routine blood tests are unnecessary. Such assumptions imply an unjustifiable blind trust which is one of the greatest arguments for compulsory prenatal blood tests.
A QUARTER OF A CENTURY AGO PUBLIC INTEREST IN THE venereal diseases began to be manifested. War came, and mobilization began. Thousands of the young men examined in the selective draft had syphilis and gonorrhea. Indeed, these two diseases were the most frequent causes of rejection, even though modern techniques for their detection were not then available.
The Congress and the President perceived the importance of stamping out the venereal diseases, for on July 9, 1918 the Chamberlain-Kahn act was signed. This act created the Division of Venereal Diseases within the Public Health Service, and set up an Interdepartmental Social Hygiene Board, since dissolved in peace time by executive order. Mobilization went forward; the navy was strengthened; the Public Health Service began the job of controlling syphilis.
Peace came. The troops were demobilized and a large part of the navy was scrapped. Public indifference even sanctioned an attempt at peacemaking with the pallid spirochete. But you can’t make peace with germs.
Then in 1936, Surgeon General Parran suddenly re-awakened public opinion. “Stop Syphilis” became a maxim after we realized the shortsightedness of the false economy of the 1920’s. The equivalent of the cost of just one battleship distributed over the last twenty years would have made syphilis a disappearing disease today.
The grave international situation may make it a necessity at present to go on building battleships and to adopt as many other national defense measures as may be required to maintain our democratic principles of government. But let’s not forget that the control of the venereal diseases is a very important step in national preparedness. And by all means let us be certain that past lessons are not forgotten. When the 1960’s roll around we may find that the military and naval precautions we were impelled to take in the 1940’s were unnecessary. But funds spent in the next two decades for the best syphilis control service will have eliminated that disease as an important public health problem twenty years hence. Thus may we adapt a preparedness measure to a humanitarian end.
Source: Vonderlehr, R. A., M.D., ” Are We Checking the Great Plague?,” Survey Graphic, Vol. 29, No. 4, p (April 1, 1940), http://newdeal.feri.org/survey/40b10.htm. New Deal Network, http://newdeal.feri.org (March 25, 2014)