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Committee Of The Board Of Health.

Venereal Diseases in New Zealand (1922) Report of the Special Committee of the Board of Health appointed by the Hon. Minister of Health online

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between the procedures which are included under this term. These are -

(1.) The supply of drugs and appliances which are made available
for use by the individual before exposure to infection. This may be
described as "anticipatory prophylaxis," and has commonly been
designated the "packet system."

The Committee condemn this procedure, for these reasons: (i) That
the system suggests a moral sanction to vice; (ii) that the
individual is lulled into a false sense of security, and may
thereby be encouraged repeatedly to expose himself to infection;
(iii) that the individual may be thereby deterred from seeking
early advice or treatment; (iv) that the drugs supplied may be used
for treating disease should it arise, and so delay may result in
seeking skilled treatment in the early stages when it is likely to
be most effective.

(2.) Treatment applied after exposure to infection. This is called
"early treatment." This term is inapplicable, as a disease cannot
be treated before it exists. It is also likely to be confused with
"abortive treatment," which implies treatment immediately on the
appearance of symptoms.

The evidence before the Committee shows that this form of
prophylaxis, if applied by skilled persons and within a few hours
of exposure, is effective in preventing disease in a great majority
of the cases in which it is used.

The Inter-departmental Committee on Infectious Diseases set up by the
Ministry of Health in 1919 in connection with demobilization, in a note
on "Prophylaxis against venereal disease," reported among its
conclusions based on service experience, "That where preventive
treatment is provided by a skilled attendant after exposure to infection
the results are better than when the same measures are taken by the
individual affected, even after the most careful instruction." After
exposure to infection there appears no reason why these diseases should
not be regarded in precisely the same manner as other infectious
diseases, and precautions taken to sterilize the parts which have been
exposed to infection.

It is to be noted that it is recommended that the prophylactic treatment
is to be carried out by some properly instructed person. This need not
necessarily be a medical man. It is suggested that this form of
prophylaxis might be carried out by an orderly at the venereal-disease
clinics. The notices posted in the public conveniences and other
suitable places indicating the existence of the clinics and the
necessity for treatment might include a guarded reference to their use
for this purpose.

This form of prophylaxis applies to males. In the case of females the
methods adopted would be also contraceptive, and the Committee do not
recommend that facilities should be provided for this.

The Committee must not be supposed to advocate prophylaxis as in any way
a substitute for continence and the cultivation of that high moral tone
that repels any suggestion of promiscuous sexual relationships, but they
feel that they could not properly ignore reference to a method of
prevention of these diseases which has proved very efficient in the
services, to which there appears no reasonable ethical objection, and
which brings their prophylaxis into line with that of other infectious
diseases.


SECTION 6. - LEGISLATION REQUIRED.

(A.) _Conditional Notification._

The only subjects of importance upon which the witnesses examined
differed materially in opinion were - (1) whether there ought to be any
system of notification of cases of venereal disease, and (2) what steps,
if any, should be taken to deal with persons suffering from such disease
in a communicable form who refused to be treated, and in some cases were
even known to be spreading the disease broadcast. Ladies who attended to
give evidence on behalf of the National Council of Women and one or two
other women's organizations objected to notification and compulsory
treatment. They argued that there was at present a "scare" on the
subject of venereal disease, and deprecated "panic legislation." They
contended that the adoption of notification would deter patients from
seeking treatment for fear of publicity. They were opposed to compulsory
treatment of recalcitrant patients, arguing that any law of the kind
would be used most oppressively against women. They contended that
reliance should be placed on greater facilities for free treatment at
the clinics, the work of women patrols, suppression of liquor, and above
all education and propaganda on moral lines.

When confronted with typical cases of difficulty already quoted some of
the witnesses admitted that it was not easy to see how such cases could
be dealt with satisfactorily without compulsion of some kind. But they
argued that, even so, it would be a greater evil if the fear of
publicity and the fear of compulsion should have the effect of deterring
sufferers from seeking treatment and so drive the disease underground.

The National Council of Women, by a substantial majority, at a recent
conference in Christchurch, carried a resolution protesting against a
proposal to introduce compulsory notification and treatment of venereal
diseases, and urging the Government to increase the facilities for free
treatment. The President of the Council, however, informed the Committee
that most of the nineteen societies affiliated to the Auckland Branch of
the National Council are in favour of some form of compulsion, but a
number of the southern branches are opposed to it. Speaking as an
individual, and not as President of the National Council of Women, she
added:

"Personally, I have no first-hand knowledge as to whether the disease is
so prevalent in the community as to demand urgent measures, but there is
an opinion among women social workers and medical practitioners, whom I
have consulted, that something should be done, and they are in favour of
compulsion under the Act, provided its administration is satisfactory.
There is no doubt that there is a genuine and widespread fear among a
large number of women that, although in the Act itself there is no
discrimination between men and women, in actual practice there will be,
and they fear that the Act will be enforced against women, and
particularly immoral women, while the men concerned will be allowed to
go free. This fear arises partly from the remembrance, particularly
among elderly women, of the old Contagious Diseases Acts, both here and
in England, and partly from the reports of the working of compulsion in
Western Australia and elsewhere. I am of opinion that there is no
serious ground for fear in view of the changed attitude in the public
mind in connection with these diseases, the fuller knowledge that people
generally have, and the high status of women in our country; also the
ready access that all persons have to the protection of the law and the
Courts in the event of false information being given, and the safeguards
embodied in the Bill as I understand it is drafted. My view is that the
objection to the compulsory clauses of the Bill would be removed in the
opinion of many women if women patrols or women police were appointed,
so that the administration of the Act in its compulsory clauses wherever
it treated women could be in the hands of those women officers."

Among the witnesses questioned on this subject there was an overwhelming
preponderance of opinion that the time had now arrived for the adoption
of notification of all cases of venereal disease by number or symbol, if
only for the purpose of getting more accurate statistics; the
notification by name of those recalcitrant patients who refused to
continue treatment until cured; and compulsory examination of those whom
the Director-General of Health had good grounds for believing to be
suffering from the disease and likely to communicate it to others, and
who refused to produce a medical certificate as to their condition. Only
three medical men expressed themselves as being against these proposals.
On the other hand, the lady doctors examined (two of them members of the
National Council of Women, and the third representing the Young Women's
Christian Association) gave evidence in favour of conditional
notification, and compulsory examination, and compulsory treatment of
recalcitrants. It should be added that all the witnesses who were
engaged in rescue work, or other work bringing them face to face with
the horrors of venereal disease, were most emphatic in their opinion
that compulsory notification and treatment should be adopted.

It is noteworthy that when the notification of ordinary infectious
disease was first proposed in England almost exactly the same arguments
were brought against the proposal as are now advanced against the
notification of venereal disease. Sir W. Foster, member for Ilkeston,
and a medical man of standing, speaking in the House of Commons in the
debate on the Infectious Diseases Notification Bill, on the 31st July,
1889, said,

"The Bill calls upon medical men to perform something more than the
ordinary duties of citizenship by requiring them to become informers of
the occurrence of diseases. The relation of a medical men to his patient
ought to be one of complete confidence, and anything that comes to the
knowledge of a medical man in the practice of his profession is
practically an inviolable secret; and I do not like any Bill to
interfere with that relationship. I know myself that one of the results
of this Bill, if passed into law, will be that in scores of cases
medical men will not be called in to attend people suffering from
infectious diseases ... I admit the difficulty of the position, but I am
anxious that no measure should pass into law which will induce the
public to keep these diseases more secret than they have been in the
past, with the risk of adding to the spreading of them. We must be very
cautious not to do anything which will prevent the public from placing
full and implicit confidence in their medical man. I can quite conceive
it to be possible that, if an outbreak of infectious disease occurs in a
populous part of London, the people may, in order to prevent exposure,
refuse to allow a medical man to come in, and in such cases we shall
have tenfold more difficulty than at present. Therefore, while I am
anxious to promote the notification of disease, I do not want the
Government to promote rebellion on the part of the public."

Needless to say, these gloomy anticipations have not been realized.
Probably the more enlightened generations to succeed us will wonder how
there could ever have been any opposition to the notification of
venereal disease, just as we to-day read Sir W. Foster's words and
marvel that any person of intelligence could have committed himself to
such statements.

Notification of infectious diseases and isolation of patients suffering
from such diseases have for many years been compulsory. Isolation, when
spoken of by opponents to a similar measure for venereal diseases, is
opprobriously described as "compulsory detention." For twenty years it
has been the law in New Zealand that an authorized medical practitioner
may examine any person suspected to be suffering from any infectious
diseases (save venereal diseases), and the Medical Officer of Health
may, if he deems it expedient in the interests of the public health,
compel the removal to a hospital of any person so suffering. This
long-established procedure as referable to venereal diseases is by
antagonists termed "compulsory examination" and "compulsory removal."

It is contended by some witnesses that notification will drive these
diseases underground; but syphilis and gonorrhœa for generations past
have been underground.

Under the present system numbers of unfortunate persons either delay
calling in medical assistance until the case has become almost desperate
so far as the patient is concerned, or they resort to unqualified
persons, with the result that in most cases what was in the first
instance a simple attack, capable of treatment, results in serious
complications most difficult to deal with. In either case the patient
may be communicating diseases to others, and should this come to the
knowledge of the Health Department it has no effective means of checking
him - no power to warn those who are being endangered by his criminal
neglect.

The Committee think there is some force in the argument that
notification by name, in the first instance, as in the case of ordinary
infectious diseases, would tend to discourage some from coming forward
for medical treatment. They recommend, therefore, the adoption of what
is known as the system of conditional notification embodied in the West
Australia Act. Under this plan the cases are notified by the doctor to
the Health Department by number or symbol only. The name is not sent in
unless the patient discontinues treatment before he is free from
infection and refuses either to go to a clinic or to another doctor. In
cases of those who "play the game," the name of the patient is kept
confidential, and does not pass beyond the medical man attending him. It
is only in cases of those who contumaciously refuse to do what is
necessary for their own safety and the safety of others that the name is
sent to the Health Department, in order that appropriate steps may be
taken in the interests of public health. Even then the name is given
only to officers who are pledged to keep it confidential.

Following are the clauses in suggestions for a Bill, drawn up by the
Health Department, which in the opinion of the Committee should in
substance be adopted: - -

"(1.) Every medical practitioner shall forthwith give notice to the
Director-General of Health, in the prescribed form, upon becoming
aware that any person attended or treated by him is suffering from
any venereal disease in a communicable form. The notice shall state
the age and sex and occupation of the patient and the nature of the
disease, but shall omit the patient's name and address.

"(2.) Every medical practitioner, other than the medical officer in
charge of a public hospital or of a clinic established by direction
of the Minister of Health, shall be paid for each such notification
a fee to be prescribed by regulation.

"(3.) The provisions of subsection (1) hereof shall apply in the
case of a child under the age of sixteen years who is suffering
from congenital syphilis.

"(4.) Whenever a patient has changed his medical adviser, in
accordance with subsection (2) hereof, the medical practitioner
under whose care the patient has placed himself shall notify the
Director-General of Health in accordance with subsection (1)
hereof, and shall include in such notice the name and address of
the previous medical adviser."

Without some such system of preliminary notification no adequate
statistics can be collected as to the prevalence of venereal diseases in
New Zealand, and no conclusion could be arrived at in the future as to
the effect of the whole or any part of the programme for combating these
scourges. Again, without such notification, and the attachment thereto
of some method of ensuring that the patient is made definitely
acquainted with his condition, it is practically impossible to enforce
the provisions of section 8 of the Social Hygiene Act for the crime of
"knowingly" infecting any other person.

Here the Committee would refer to case 2 quoted above. Of what use is it
to provide free clinics if those who make use of them are permitted, as
soon as the urgent symptoms are relieved, to disseminate disease
broadcast, widening the circle of infection? Again, where is our
humanity if no step is to be taken to try to prevent a syphilitic child
being born to the man in case 1?

A very valuable result of anonymous notification would be the
possibility afforded of observing any unusual "flare-up" or succession
of cases, especially in country districts and small towns. Study of case
4 will show the great value it would have been to have a record of an
unusual increase of syphilis in that township, giving an opportunity for
prompt investigation by the Medical Officer of Health for the district.

(B.) _Compulsory Examination and Treatment._

This question obviously presents more difficulty than that of
notification, but it is clear that unless some means are provided of
bringing under treatment and, if necessary, isolating persons who are
suffering from highly contagious diseases, and who will not avail
themselves of medical treatment although this is provided free of cost
by the State, and who are knowingly or recklessly communicating the
disease to others, it will be impossible to keep in check this terrible
scourge. Without such provision any abandoned woman, as in case 4, or
any male libertine, may continue to sow disease broadcast without any
power to stop them. Failing some such measure, table articles and food
may continue to be smeared by hands soiled with syphilitic material, as
in case 1; section 6 of the Social Hygiene Act remains mere useless
verbiage, and the infecting of innocents, as in case 3, may continue
unchecked.

Legislation dealing with this subject needs to be carefully framed with
suitable safeguards, but the Committee think that an amendment of the
Social Hygiene Act on the lines proposed by the Department of Health
should be adopted. These provisions are: -

(1.) That whenever the Director-General of Health has reason to
believe that any person is suffering from venereal disease, and has
infected or is liable to infect other persons, he may give notice
in writing to such person directing him to consult a medical
practitioner, and to produce within a time specified in the notice
a certificate from such medical practitioner to the satisfaction of
the Director-General of Health that such person is or is not
suffering from venereal disease.

(2.) Should the person not comply with this request, the
Director-General of Health may obtain a warrant from a Magistrate
ordering such person to undergo examination to prove the existence,
or non-existence, of venereal disease.

(3.) Making it possible for a Magistrate, on the application of the
Director-General of Health, to order the detention in a hospital or
other approved place of a person who is likely to be a danger to
other persons until that person is cured of venereal disease.

These provisions are applicable equally to both sexes, and the Committee
see no reason to fear that the law would not be carefully and
impartially administered. If it should appear that more women than men
came under the operation of the law this result would be due to the fact
that, as disclosed in the evidence, a much larger proportion of women
than men fail to seek treatment, and of those treated a much larger
proportion of women fail to continue treatment until no longer
infectious.

It is hardly conceivable that a responsible officer, such as the
Director-General of Health, would take action under these provisions
unless he had strong reason to believe that such action was justified.
But, even if he makes a mistake or is misinformed, the worst that can
happen to an innocent person wrongfully suspected is that he or she will
be required to produce a medical certificate, which can be procured free
of cost from any hospital or V.D. clinic. This is wholly different from
the provisions of the Contagious Diseases Act, under which a woman
suspected of prostitution was liable to be arrested by a constable in
the street.

The Committee recommend that the serving of notices, &c., under these
sections be done by officers of the Health Department and not by the
police. They also recommend that all proceedings taken under any Act
having reference to venereal diseases should be heard in private unless
the defendant applies for a hearing in open Court.

With regard to the effects of the actual operation of notification,
examination, and isolation, the Commissioner of Public Health for West
Australia, under date 25th August, 1922, advises the Committee that
there is an increase in the number of cases attending public clinics,
and that this is regarded not as evidence of increased incidence, but of
increased interest and appreciation of early treatment by those
suffering from the diseases.


SECTION 7. - MARRIAGE CERTIFICATE OF HEALTH.

The Royal Commission on Venereal Disease reported that there was a vast
amount of ignorance as to the dangers arising from the sexual
intercourse of married persons one of whom had previously to the
marriage contracted syphilis or gonorrhœa. The effect upon the
birth-rate, and the misery caused during married life, and in many cases
to the offspring who survive, as they pointed out, are most serious, and
the fact that the actual cause of the trouble often remains unknown and
unrecognized prevents the calamity from serving the purpose of example
or warning.

Some of the witnesses heard before the present Committee have urged that
a certificate of good health, or at least a certificate of freedom from
communicable disease, should be required from each party to a proposed
marriage before the Registrar issued a license to marry. The Royal
Commission considered that "it would not be possible at present to
organize a satisfactory method of certification of fitness for
marriage." The National Birth-rate Commission, however, reported that in
their opinion the question should be reconsidered with a view to
legislation.

There is much to be said in favour of such a proposal from the point of
view of national health. If the system were adopted the certificate
should, in the opinion of the present Committee, include freedom from
mental disease as well as freedom from communicable disease. But there
are manifest difficulties in the way, chiefly in regard to the delicate
and searching examination which would be required in the case of women
before a doctor could certify positively to the absence of communicable
disease.

The Committee recommend that instead of a medical certificate each party
to a proposed marriage should be required to answer appropriate
questions in regard to the presence or absence of communicable and
mental disease, and to make a sworn statement before the Registrar as to
the truth of the answers. It should be the duty of the Registrar to
communicate the contents of the statements to the other party in the
event of any admission of the presence of communicable disease.

In addition to the penalty for making a false statement it might be
provided, as in the Queensland Act, that venereal disease shall be a
ground for annulling a marriage contract when one party is suffering at
the time of marriage from such disease in an infectious state, provided
the other party was not informed of the fact prior to marriage.

The Committee would also recommend the adoption of a further provision
that it should be the duty of a medical practitioner attending a case of
venereal disease which is or is likely to become infective, if he has
reason to believe that the patient intends to marry, to warn him or her
against doing so, and if he or she persists it should be the duty of the
doctor forthwith to notify the case by name to the Director-General of
Health, whose duty it should be to inform the other party. It should
also be provided that _bonâ fide_ communications made in such a case,
either by the Director-General of Health or the doctor, to the other
party to the marriage, or to the parents or guardian of such party,
shall be privileged.


SECTION 8. - TREATMENT BY UNQUALIFIED PERSONS.

The evidence given before the Committee shows that while reputable
chemists refer to a medical man patients coming to them for treatment
for venereal disease, and while these constitute the great majority of
the profession, there are still far too many cases of venereal disease
treated by chemists, herbalists, chiropractors, and other unqualified
persons. The treatment of venereal disease has become a specialized
branch of medicine, and many general practitioners prefer to refer such
cases to experts. The result of trusting to unqualified persons for the
treatment of such serious and difficult diseases is that the patient
usually drifts on uncured, and serious complications may occur. One
specialist in venereal disease informed the Committee that of 200 of his


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Online LibraryCommittee Of The Board Of HealthVenereal Diseases in New Zealand (1922) Report of the Special Committee of the Board of Health appointed by the Hon. Minister of Health → online text (page 5 of 7)