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legal commitments, where social service procedures will supple-
ment medical treatment in the rehabilitation program.

6. Enactment of prenatal and premarital health laws providing
for blood tests of expectant mothers and prospective marital
partners.

' 7. Extension of facilities for diagnosing and treating syphilis
and gonorrhea, and use of Negro physicians, nurses, and medical
social workers in clinics where Negro patients form the clientele.

8. An early conference wherein judges, prosecutors, police, health,
and social service workers can present their views to each other.

9. A strengthening of prostitution laws so that the "call house"
and "beer joint" situations can be dealt with more adequately.

10. A continuance of the public education program.



524 JOTTBNAL, OF SOCIAL HYGIENE

Adding measurably to the conferees' basic data was the report by
Dr. James A. Nolan, director, Washington Criminal Justice Asso-
ciation, who summarized the results of a late study analysing 2,559
prostitution arrests and their court dispositions. Similarly the
Institute owes a real debt to such agencies of national scope as
the U. S. Public Health Service, Social Protection Division, and
the American Social Hygiene Association whose background and
experience were so extensively represented in the facts, figures and
philosophy presented by Dr. Vonderlehr, Eliot Ness, Major Brum-
field, Bascom Johnson et al.

The luncheon session was made notable by the address of Senator
Robert M. LaFollette who epitomized the fine Congressional support
and understanding achieved for social hygiene activities in recent
years. As co-sponsor of the La-Follette-Bulwinkle Act authorizing
annual appropriations to the United States Public Health Service
for aiding Federal and State venereal disease control, and as a
consistent and devoted advocate of all that is best in social protec-
tive measures, Senator LaFollette always is a welcome guest of those
who work to improve social welfare and public health.

One measure of the Institute's value and importance was the
amount of space accorded it by the press. Even the tremendous
pressure of war and political news and Washington papers must
give broad coverage to these happenings couldn't keep the Insti-
tute off the front pages. So interesting and timely were its facts
and discussions, so vital were they to the whole public, that Wash-
ington's newspapers gave the proceedings many columns of space
on the most prominent pages. Among the results of this publicity
surge was the prompt calling of a meeting by Senator Pat McCarran,
chairman, Senate Committee on the District of Columbia, to consider
strengthening Washington's defenses against prostitution. The
District Commissioners have taken a fresh interest in this field,
the police have conducted extensive raids on places allegedly used
for prostitution, the judges and prosecuting authorities have pledged
whole-hearted cooperation, the public has become more alert, and
the whole community consciousness of the civic menace involved
in the prostitution racket has been aroused and energized.

Now that the ball is "in play" its up to every Washington indi-
vidual to help keep it rolling. For the problems are not merely
police and health department responsibilities. Theirs is largely
a "salvage" duty. The main lines of social protection rest now, as
always, in the school, the church, and above all the home.



"WHEN BROTHELS CLOSE, V.D. EATES GO DOWN "

PROSTITUTION IN THE SPREAD OP VENEREAL DISEASE
IN AN ARMY CANTONMENT AREA *

BASCOM JOHNSON, JR., M.D., M.P.H., P.A. SURGEON (E)

United States Public Health Service, El Paso City-County Health Unit,

El Paso, Texas

This is an epidemiological study of the principal places and sources
of venereal infections among Army personnel in the El Paso area.
El Paso is a city of almost 100,000 population (67 per cent Mexican),
situated on the Mexican border in the extreme western corner of
Texas. Juarez, Mexico, with a population of approximately 50,000,
is the largest border city in Mexico and is located on the Mexican
side of the Rio Grande within easy walking distance of El Paso. Fort
Bliss, Texas, an expanding military cantonment area with, at present,
about 25,000 troops, is located within a short distance of the El Paso
city limits.

In March 1941, when this study was started, commercial prostitu-
tion was flourishing in El Paso. There were nine well known houses
of prostitution under police surveillance and in some respects almost
under police protection. The 40 to 70 women working in these houses
were examined once a week in the city police department by local
health department personnel. The examination consisted of a urethral
and cervical smear taken from each prostitute. No cultures for gon-
orrhea were made. Serologic tests for syphilis were made once every
six weeks unless more frequent tests were indicated by the weekly
physical inspections. Infected women were placed under quarantine
in the county jail until sufficient treatment had rendered them
potentially noninfectious.

In Juarez, prostitution was even more flagrant. The Mexican
authorities claimed that there were 300 commercial and 80 clandestine
prostitutes in Juarez. Prospective clients were openly solicited by
many taxi drivers and a considerable number of young boys.

Through the cooperation of Army authorities frequent trips were
made by the writer to the venereal disease wards of the two Army
hospitals in the vicinity. Each patient with a venereal disease was
questioned as to what exposures he might have had during the incuba-
tion period of his infection. A careful explanation that the purpose
of the study, was to discover where the venereal diseases were coming
from was made at the beginning of each interview. The fact was
stressed that the information solicited would be kept confidential.

* A paper presented at the first session of the Epidemiology Section, 71st Annual
Meeting of the American Public Health Association, St. Louis, October 27, 1942.

525



526

In the interview the point was emphasized that the writer was an
officer of the United States Public Health Service and not in the
Army and that consequently the detailed information sought would
not be seen by the patient's superior officers or any other Army
personnel. Only the final statistical analysis would be made available
to the Army and other health workers. If the patient being inter-
viewed showed any embarrassment or any reticence in talking freely
of his experience, no history was taken and that patient was not
included in the study. The names of the possible sources of infection
were not even solicited as this information had been previously
obtained by the medical officers on the ward. The addresses of the
source-cases were obtained.

By this method of approach, it is believed that most of the
motives for soldiers to lie about such matters were eliminated. The
cooperation under the above circumstances has been unusually good.
In only 19 instances out of more than 1,900 interviews did the patient
show embarrassment or reticence in discussing his history. No history
was taken in such cases. The great majority appeared eager to discuss
their problems. This is illustrated by the fact that, usually, within a
few minutes of the author's entry into the ward, he was surrounded
by a group of soldiers asking questions about the venereal diseases.
Every effort was made to answer all such questions, and it was felt
that, by doing so, an informal atmosphere was induced which
relieved reticence in most instances.

For the purposes of this study rather arbitrary incubation periods
have been chosen. An incubation period of from 48 hours to 14 days
for gonorrhea, up to 14 days for chancroid disease, and up to six
weeks for primary syphilis were the limits decided upon. If the time
interval between the date of exposure and the date of onset was greater
or less than these incubation, periods, the case was not included in
the final statistical analysis.

Of the 1,939 case histories that have been collected to date, 795 have
been excluded from the study. In 90 cases, there were so many
exposures at different addresses during the incubation period of the
disease in question that it was impossible to decide which exposure
had been responsible for the infection. In 342 cases, the diagnosis
was doubtful. In 226, the incubation period between exposure and
onset of infection was either too long or too short. This eliminated
some histories which might be subject to the criticism of questionable
veracity.

In 100 cases, there was considerable evidence that the gonorrhea
in question might have been a recurrence. In 37 cases, either the
patient was too drunk at the time of exposure to give a reliable his-
tory, or the case record could not be located to verify the diagnosis.

This study is based on the Army's final diagnosis. The diagnosis
of gonorrhea rests on a positive Gram stain. The diagnosis of chancre
syphilis rests on a positive dark-field examination or on a combination
of clinical symptoms, plus a positive serological test for syphilis in the
presence of a negative past history and negative serology on induction.
The diagnosis of chancroid has had no laboratory confirmation. It
has been based on the history and clinical appearance of the lesion



WHEN BROTHELS CLOSE V.D. RATES GO DOWN



527



in the presence of three consecutive negative dark-field examinations
and repeatedly negative serological tests for syphilis for three months
after onset. No skin tests for chancroid or Frei tests were being
routinely used at either hospital. More recently the therapeutic trial
of sulfonamide powder locally has been found useful in making a
diagnosis of chancroid.

A total of 1,144 cases are included in this study 840 cases of
gonorrhea, 205 cases of chancroid, and 99 cases of syphilis. A dis-
proportionate number of syphilis cases had to be excluded from the
study because of the longer incubation period of syphilis in compari-
son with gonorrhea and chancroid. This longer incubation period
permitted multiple exposures at different addresses and it was impos-
sible therefore to decide which exposure had been responsible for
the infection.

Of the 840 cases of gonorrhea, 53 per cent were presumably infected
in a house of prostitution. Seventy-three per cent of the 205 cases of
chancroid and 61 per cent of the 99 cases of syphilis claimed infection
in a house of prostitution. The prostitute has been found to be the
major source of infection in this study.

However, during the course of this study several administrative and
diplomatic changes occurred which had a definite effect on the avail-
ability of the commercial prostitute in the El Paso-Juarez area. The
relative role of the prostitute and the "pick-up" as sources of infec-
tion is depicted under varying circumstances in tables I through VI.
The variations in the local Army venereal disease rate during the
period of this study is shown in Figure I.

During the first three and one-half months of the study (March 19,
1941-June 30, 1941) prostitution conditions were flagrant both in
El Paso and Juarez. (Table /.)

TABLE I

Place of Exposure and Source of Infection in 369 Cases of Venereal Disease
Before Closure of Houses of Prostitution in El Paso And While Prosti-
tution Was Also Flagrant in Juarez, Mexico.
March 9, 1941-June 80, 1941

Gonorrhea Chancroid Total



Num- Per
ber cent
Place of Exposure:

El Paso, Texas 17 51 . 5

Juarez, Mexico 6 18.2

Elsewhere 10 30.3



Num- Per
ber cent



Num- Per
ber cent



156
64
56



56.5
23.2
20.3



37

20

3



61.7

33.3

5.0



Num- Per
ber cent

210 56.9
90 24.4
69 18.7



Total



33 100.0 276 100.0



60 100.0 369 100.0



Source of Infection:

House of prostitution

Pick-up i

Friend or other source ....



25
4
4



75.8
12.1
12.1



200
45
31



72.5
16.3
11.2



47

10

3



78.4

16.6

5.0



272 73 . 7
592 16.0
38 10.3



Total
Bar, dance hall or street.



33 100.0 276 100.0 60 100.0 369 100.0



2 Of the 59 pick-ups, 16 (4.3 per cent of the 369 sources) were prostitutes, the
criterion being that the exposure was paid for.

Prostitution caused a total of 78.0 per cent of the 369 infections.



528 JOUBNAL OP SOCIAL HYGIENE

The women in the nine well-known houses of prostitution in El Paso
were being subjected to weekly examination by conscientious health
department personnel at the city police department. During this
period it was found that 74 per cent of the infections were pre-
sumably coming from houses of prostitution and 11 per cent were
apparently coming from "non-prostitute pick-ups." Of the total of
369 cases in this part of the study 57 per cent incriminated El Paso.
The remaining 43 per cent were apparently fairly evenly divided
between Juarez and communities outside the El Paso-Juarez area.



FIGUEE I

Corrected Army venereal rates for the entire Fort Bliss area from November 1941

through July 1948. (Bates are expressed as the number of

cases per 1,000 men per annum.)



85
80

70

.-jjate. for Fort Bliss area for IJ-ajontjh. j^-^
period ending November 1941



50



40




40,5 Rateor the entire /flrmy rac year 1941-40.5



so,- 81

25



10




Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug.
1941 1942



However, of 183 cases of venereal diseases in which the place of
exposure was said by the infected soldiers to have been in El Paso,
154 of them or 84 per cent incriminated one or more of the nine houses
of prostitution where the women were examined once a week:(l)
The inadequacy of the periodic examination of prostitutes in con-
trolling the spread of venereal disease is amply illustrated by these
figures 84 per cent of the disease coming from El Paso was traced
to the prostitutes being examined once a week.



'WHEN BROTHELS CLOSE V.D. BATES GO DOWN



529



There followed a three month period (Table II July 1, 1941-Sep-
tember 30, 1941) when the houses of prostitution in El Paso were closed
and the periodic examination of these women by the health department
had been abandoned. However, prostitution was still flagrant in
Juarez and at one-half the price, 50 cents instead of one dollar.
During this period, the proportion of venereal disease coming from
El Paso seemed to decrease about 25 per cent. But, the proportion
coming from Juarez apparently increased by an equal amount. The
role of the non-prostitute pick-up seemed to increase somewhat. There
was no appreciable decrease in the army venereal rate during this
period.

TABLE II

Place of Exposure and Source of Infection in 160 Cases of Venereal Disease

Acquired After Closing of Houses of Prostitution in El Paso, But

While Prostitution Was Flagrant in Juarez, Mexico.

June SO, 1941-September SO, 1941

Syphilis Gonorrhea Chancroid Total



Place of Exposure:
El Paso Texas


Num- Per
ber cent


i
Num-
ber

39
73
, 37


\
Per
cent

26.2
49.0
24.8


Juarez, Mexico






Elsewhere


2


100.0


Total




2


100.0
50.0


149

78
44
27


100.0

52.4
29.5
18.1


Source of Infection:
Houses of prostitution..


1


Friend or other source . .


1


50.0



Num- Per
ber cent



Num- Per
ber cent



11.1

77.8
11.1



40
80
40



25.0
50.0
25.0



9 100.0 160 100.0



8 88.9

'i ii.'i



87 54.4
442 27.5
29 18.1



Total .



2 100.0 149 100.0



9 100.0 160 100.0



1 Bar, dance hall or street.

2 Of the 44 pick-ups, 15 (9.4 per cent of the 160 sources) were prostitutes, the
criterion being that exposure was paid for.

Prostitution caused a total of 6S.8 per cent of the infections.



On October 1, 1941, El Paso houses of prostitution reopened rather
quietly and were allowed to operate surreptitiously off and on till
about June 19, 1942. (See Table III). However, as soon as the
houses reopened the amount of venereal disease said to be coming
from prostitution increased significantly and the amount attributed
to El Paso started to increase.

On December 8, 1941, following the declaration of war, the Inter-
national Bridge to Juarez was closed to American soldiers. There
followed an 82 day period (December 8, 1941-February 27, 1942)
when the prostitute in Juarez was no longer available but during
which the houses of prostitution in El Paso were periodically opened
and closed. (See Table IV). After the closure of the International
Bridge to soldier traffic, the total amount of venereal disease coming
from prostitution apparently dropped from 73 per cent to 48 per cent.



530



JOUBNAL OP SOCIAL HYGIENE



TABLE III

Place of Exposure and Source of Infection in 204 Cases of Venereal Disease

Acquired During a Period When El Paso's Houses of Prostitution

Were Operating Surreptitiously and Prostitution Was Flagrant

in Juarez, Mexico.
October 1, 1941-December 7, 1941

Syphilis Gonorrhea Chancroid Total

Num- Per Num- Per Num.- Per Num- Per

ber cent ber cent ber cent ber cent
Place of Exposure:

El Paso, Texas 5 33.3 47 34.6 17 32.1 69 33.8

Juarez, Mexico 8 53.4 47 34.6 28 52.8 83 40.7

Elsewhere 2 13.3 42 30.8 8 15.1 52 25.5



Source of Infection:




Houses of prostitution. . .


. 11 73.3


Pick-up i


3 20.0


Friend or other source . . .


1 6.7


Total .


15 100.0



15 100.0 136 100.0 53 100.0 204 100.0



84
31
21



61.8
22.8
15.4



43
5
5



81.2
9.4
9.4



138 67.7
392 19.1
272 13.2



136 100.0



53 100.0 204 100.0



1 Bar, dance hall or street.

2 Of the 39 pick-ups and other sources 11 (5.4 per cent of the 204 sources) were
prostitutes, the criterion being that exposure was paid for.

Prostitution caused a total of 73.1 per cent of the infections. Twenty-eight
cases or 13.7 per cent caused by non-prostitute pick-ups.



TABLE IV

Place of Exposure and Source of Infection in 143 Cases of Venereal Disease

Acquired During a Period When El Paso's Houses of Prostitution Were

Operating Surreptitiously and the International Bridge to

Juarez, Mexico Was Closed to Soldier Traffic.

December 8, 1941-February 27, 1942



Syphilis Gonorrhea Chancroid



Num- Per
ber cent



Total





Num- Per
ber cent


Num- Per
ber cent


Place of Exposure:






El Paso, Texas


8 66 . 7


34 36.2


Juarez, Mexico






Elsewhere ,


, . . 4 33 3


60 63 8








Total .


12 100.0


94 100.0



Num- Per
ber cent



29
3
5



78.4

8.1

13.5



71

3

69



49.6

2.1

48.3



37 100.0 143 100.0



Source of Infection:

House of prostitution 3

Pick-ups i 9

Friend or other source . .



25.0
75.0



14
57
23



14.9
60.7
24.4



18

9

10



48.7
24.3
27.0



35 24.5
752 52.4
332 23.1



Total



12 100.0 94 100.0 37 100.0 143 100.0



1 Bar, dance hall or street.

2 Of the 75 pick-ups and other sources, 33 (23.2 per cent of the 143 sources)
were prostitutes, the criterion being that exposure was paid for.

Prostitution caused a total of 47.8 per cent of the infections. Forty-two cases
or S9.4 per cent caused by non-prostitute pick-ups.



"WHEN BROTHELS CLOSE V.D. RATES GO DOWN" 531

Only three (2 per cent) out of the 143 cases exposed during this
period claimed to have contracted their disease in Juarez. Of the
remaining 140 cases, 71 were exposed in El Paso and 69 were exposed
outside the El Paso-Juarez area. The amount coming from houses
of prostitution apparently dropped from 68 per cent for the period
before the bridge to Juarez was closed to 25 per cent after closure.
However, during this period the "pick-up" began to assume a more
important role as a source of infection.

As is shown in the graph, Figure 1, the venereal disease rate dropped
sharply. The Army venereal rate for that area had averaged 63.5 per
thousand per annum for a 17 month period through November, 1941.
The corrected rate (corrected for cases whose exposure occurred prior
to induction) for November was 83 per thousand. Despite the fact
that a large proportion of soldier exposures occur the first ten days
after pay-day, the rate dropped to 54 for December and to 31 for
January.

On pay-day night February 28, 1942, the International Bridge to
Juarez was reopened to soldier traffic. There followed a period of
three and one-half months when open houses of prostitution again
became readily available to soldiers in Juarez and while houses of
prostitution were intermittently available in El Paso. (Table V.)
The amount of venereal disease coming from houses of prostitution
appeared almost to double. The 209 cases studied which occurred
during this period were apparently fairly evenly divided as to place
of infection; 35 per cent coming from El Paso; 35 per cent from
Juarez and about 31 per cent coming from elsewhere. During this
period the "pick-up" evidently played a less important role as a
source of infection.

The corrected Army venereal rate which had continued its decrease
into March started up again. From a peak low of 25 cases per
thousand per year it rose to 43 for April and 47 for May. (Figure I) .

On June 19, 1942, a policy of repression was started in Juarez.
If you are acquainted with border conditions, you will realize that
this was no mean accomplishment. Prostitution in those Mexican
border communities is often well entrenched in the political life as well
as the social mores of the people. Most of the credit for the attain-
ment of repression in Juarez should go to Dr. Spoto of the Pan-
American Sanitary Bureau and to Dr. Vellela and Dr. Vellande of
the Mexican Federal Department of Health. The red light district
was closed and all but a few houses of prostitution were closed tight.
With Juarez as an example, a more conscientious policy of repression
was started in El Paso. Since that date only 59 case histories which
could be included in the study have accumulated. (Table VI). When
tabulated, they suggest that the proportion of venereal disease coming
from prostitution and from Juarez is on the decrease, while the pro-
portion coming from the non-prostitute pick-up is increasing.

The corrected local Army venereal rate has started to decline again.
From a. peak of 47 in May it dropped to 38 in June and 28 in July.
In August the rate was still under 30 (29). (Figure I).



532



JOURNAL OF SOCIAL HYGIENE



TABLE V

Place of Exposure and Source of Infection in 09 Cases of Venereal Disease

Acquired During a Period When El Peso's Houses of Prostitution Were

Operating Surreptitiously and the International Bridge to

Juarez, Mexico Had Been Reopened to Soldier Traffic.

February 28, 1942-June 19, 1942



Syphilis Gonorrhea Chancroid

Num- Per Num- Per Num- Per

ber cent ber cent ber cent
Place of Exposure:

El Paso, Texas 17 53.2 41 30.8 14 31.8

Juarez, Mexico 8 25.0 40 30.1 24 54.6

Elsewhere 7 218 52 39.1 6 13.6



Total



Num- Per
ber cent



72
72
65



34 . 5
34 5
31.0



Total



32 100.0 133 100.0 44 100.0 209 100.0



Source of Infection:

House of prostitution ....

Pick-up i

Friend or other source ....



20
9
3



62.5

28.1

9.4



o7
46
30



42.8
34.6
22.6



32

10

2



72.8

22.7

4.5



109 52.2
652 31.0
35 16.8



32 100.0 133 100.0 44 100.0 209 100.0



Total

1 Bar, dance hall or street.

2 Of the 65 pick-ups, 21 (10 per cent of the 209 sources) were prostitutes, the
criterion being that exposure was paid for.

Prostitution caused a total of 62.2 per cent of the infections. Forty-four cases
or 21 per cent caused by non-prostitute pick-ups.



TABLE VI

Place of Exposure and Source of Infection in 59 Cases of Veneral Disease

Acquired During a Period When El Peso's Houses of Prostitution Were

Well Eepressed and a Policy of Eepression Was Being Fairly

Well Enforced in Juarez, Mexico.

June 19, 1942-August 25, 1942

Syphilis Gonorrhea Chancroid Total



Place of Exposure:
El Paso, Texas.. .
Juarez, Mexico . .
Elsewhere .



Num- Per
ber cent



Num- Per
ber cent



Total



5 100.0



19

6

27



36.6
11.5
51.9



Num- Per
ber cent

2 100.0



Num- Per
ber cent



21

6

32



35.6
10.2
54.2



5 100.0 52 100.0



Source of Infection:

House prostitution

Pick-up i

Friend or other source ....

Total .



20.0
60.0
20.0



13 25.0

30 57.7

9 17.3



2 100.0 59 100.0



1 50.0 15 25.4

332 56.0

1 50.0 112 18.6



5 100.0 52 100.0



2 100.0 59 100.0



1 Bar, dance hall, or street.

2 Of the 33 pick-ups and other sources 5 (8.5 per cent of the 59 sources) were
prostitutes, the criterion being that exposure was paid for.

Prostitution caused a total of S2.2 per cent of the infections. Twenty-eight



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