OF VENEREAL DISEASES!

WILBUR A. SAWYER, M.D.

Secretary of the California State Board of Health; Clinical Professor of Preventive
Medicine and Hygiene, University of California Medical School

THE CALIFORNIA PROGRAM FOR THE PREVENTION J

No new scientific studies or ingenious administrative methods
lie at the basis of California’s program for the prevention of
venereal diseases. The reasons why the work has received so
much attention, and why I have been honored by being invited
to explain the plan to this conference, are doubtless that in
California syphilis and gonorrhea have at last been definitely
classed among the most important preventable diseases, and
because state and local health officials have initiated vigorous
measures for reducing their prevalence.

While I feel some pride in pointing to the priority of California
in establishing a well-financed state-wide attack on venereal
diseases, I feel much more strongly a sense of chagrin that the
sanitarians of America should have left this important work
until it was: almost foreed upon them by a world war and an
aroused public sentiment. For many years the fundamental
facts of the methods of transmission and the possible methods of
prevention of syphilis and gonorrhea have been well understood,
and it has been realized that in importance these two diseases
are probably equal to tuberculosis and that they are certainly
much more preventable. We have all pleaded impotence, and
some of us have explained our helplessness by pointing to the
three bugaboos,—morals, political opposition, and professional
secrecy.

While the duly constituted guardians of the public health have
been sleeping or making feeble beginnings, other agencies, in-

1 Read before the Conference of the Northwestern States on the Prevention of
Venereal Diseases, arranged by the Western Social Hygiene Association, and held
in Tacoma, Washington, Detember 10 and 11, 1917.

25
26 SOCIAL HYGIENE

cluding social hygiene associations, university hygiene depart-
ments, and semi-religious organizations, have been laying a
solid foundation on which the health authorities can build. Now
that a calamity of sufficient magnitude, the war, has awakened
us, we find that there is a strong demand for the control of syphilis
and gonorrhea through the enforcement by health officials of the
obvious methods of prevention, .conirolled by epidemiological
studies. Such a program is so popular that all factions support
it, and it is difficult to organize the work fast enough to keep the
various lines of activity properly codrdinated.

Several of the preliminary steps in venereal disease control in
California must be mentioned. In 1911, while Dr. William F.
Snow was Secretary of the State Board of Health, the legislature
added syphilis and gonorrhea to the list of communicable diseases
which were required to be reported, and provided that these two
diseases shall be reported by office number only. In the Cali-
fornia Public Health Act, section 138, rule 2, it is provided that
cases of any disease in a list including syphilis and gonococcus
infections may be isolated by the State Board of Health or the
local health officer if such action is necessary for the protection
of the public health. This last mentioned power was seldom
exercised up to the beginning of the present program.

Three years ago the State Hygienic Laboratory began making
free Wassermann tests for the physicians of the state and sent
out containers in which the specimens could be mailed. The
city of San Francisco has been making similar tests for physicians
whose patients are unable to pay for tests in private laboratories.

When the Secretary of War asked the codperation of the
governors of the states in preventing the evil effects of liquor
and vice among the soldiers, Governor William D. Stephens sent
out a strong letter calling on public officials for a rigid enforce-
ment of the laws bearing on these subjects. The state laws
include a Red Light Abatement Act.

On May 5, 1917, the State Board of Health passed resolutions
calling on all mayors to demand from the appropriate officials
an active policy of protection of enlisted men from venereal dis-
ease, and asking a report of their plans for meeting the venereal

PROGRAM FOR PREVENTION. OF VENEREAL DISEASES 27

disease problem. In response to this resolution Dr. A. E. Banks,
health officer of San Diego, organized an excellent system of
codperation between army, navy, county, and municipal officials
in venereal disease control, including the repression of prosti-
tution and the searching out and isolating of women who had
infected soldiers. .

Soon after the war broke out the State Board of Health began
coéperating with the Western Department by furnishing various
kinds of expert service. A state-wide system of reciprocal noti-
fieation of communicable diseases, including venereal diseases,
between the post surgeons and the local health officers was begun.

In order to make venereal disease control more effective a
conference was held in San Francisco on July 21, 1917. This |
conference was attended by representatives of the United States
Army, Navy and Public Health Service, the State Board of Health,
the mayors, chairmen of boards of supervisors, district attorneys,
city and county health officers, chiefs of police, and sheriffs,
of thé cities and counties near the army and navy encampments
of the San Francisco Bay region. The following program. was
adopted unanimously :—

1. Prostitution is to be suppressed; vigorously and continuously,
through the enforcement of the state laws, and the issuance of certi-
ficates of health to prostitutes shall be no part of the program.

2. Prostitutes brought to the attention of the police or health
authorities are to be examined; and all persons, male or female, capable
of spreading venereal disease are to be isolated, under the provisions
of the Public Health Act or local ordinance, and treated at public expense
as long as there is danger, in the opinion of the health officer, of their
exposing others,

3. Under no circumstances are infected prostitutes to be “floated”
into other communities, and if they are known to go from one com-
munity to another, the health officials of the places of destination are
to be notified at once.

4, The state law, requiring the reporting of syphilis and gonococcus
infections by physicians’ office numbers, is to be enforced to the letter,
and in addition, physicians are to be urged to obtain, and furnish to the
local health officers, the names of the persons who are suspected of
28 SOCIAL HYGIENE

disseminating infection. The local health officers are thereupon to
investigate and supervise or isolate infectious cases, according to the
circumstances.

5. To provide and encourage the instruction of young men and
women in the advantage of a clean life and the dangers from venereal
diseases.

6. To provide adequate opportunities for expert diagnosis, treat-
ment, and advice for infected persons financially unable to secure
proper attention for themselves, and to encourage the continuance of
treatment until the patient is cured, or at least becomes noninfectious.

7. To provide free laboratory tests for syphilis and gonococcus
infections for physicians, and to encourage greater use of the free
tests for these diseases available at the laboratory of the Bureau of
Communicable Diseases of the State Board of Health.

In order to assist in the discovery of those prostitutes most
dangerous to the soldiers and sailors, Colonel Charles Lynch, of
the Western Department, devised a special report blank on which
he required all post surgeons to report venereal disease cases
together with the alleged sources of infection. These reports
are of great value in helping discover the most dangerous prosti-
tutes, public or clandestine, so that they can be investigated
and brought under such isolation and treatment as may be
necessary. The reports also furnish data useful in the epidemio-
logical studies of the geographical distribution of foci of venereal
disease.

The 12th Naval District soon adopted a similar set of forms and
entered into the plan. The San Francisco Health Department
codperated very actively in this program and set aside an entire
ward in the San Francisco Hospital for patients under official
isolation.

When this stage of development was reached, the State Mili-
tary Welfare Commission came to the conclusion that an ex-
tension of the program above described would be the most
effective way of combating the venereal disease problem of the
soldiers and sent a delegation to Governor Stephens to ask for
$60,000 to finance a Bureau of Venereal Diseases in the State
Board of Health for two years. At the end of that time the

PROGRAM FOR PREVENTION OF VENEREAL DISEASES 29

legislature will have an opportunity to make an appropriation
for the continuance of the Buréau on a permanent basis. .

The delegation laid the plan before Governor Stephens on
August 13th. He heartily approved of the plan, and the money
requested became immediately available from war emergency
funds. The Bureau of Venereal Diseases was created in the
State Board of Health with the Secretary of the Board acting
temporarily as director. The functions of the Bureau were
tentatively outlined in the statement presented to the Governor
as follows:—

DIRECT CONTROL °

1. To secure the reporting of cases of syphilis and gonococcus in-
fection, together with the probable sources of infection, by physicians
and by the medical officers of the army and navy.

2. To investigate, with the assistance of local officials, any sus-
pected foci of infection and to isolate infectious persons whenever it
is necessary to prevent their spreading disease.

3. With the codperation of cities and counties to care for the men
and women isolated on account of venereal disease in public isolation
hospitals until the patients are no longer infectious.

4. Asfar as possible to secure the medical examination for venereal
diseases of male and female prisoners and other appropriate groups,
and to provide for their isolation and treatment so that, they will not
spread disease when released.

5. Through the operation of this plan to prevent the heretofore
common evil of one community ‘‘passing on’ to another its undesirables,
thereby multiplying foci of infection.

6. To focus on this subject the social forces necessary to give former
prostitutes, after thes have been put into good physical condition, an
opportunity to enter into productive occupations under conditions fair
to themselves and to the community.

PUBLIC OPPORTUNITIES FOR DIAGNOSIS AND TREATMENT

1. To investigate all clinics or hospitals treating venereal diseases
and to bring into existence adequate day and evening clinics and
opportunities for hospital treatment for syphilis and gonorrhea.

2. To make a, list of accredited clinics in which venereal diseases are
treated, accrediting only those which reach |high standards in staffs,
equipment and results.
80 SOCIAL HYGIENE

3. To purchase and issue, without charge, approved public hospitals
and clinics, salvarsan or approved substitutes, for use in making cases
of syphilis non-infectious in the shortest possible time.

4. To arrange with city laboratories to give free diagnostic tests for
syphilis and gonococcus infections, and to encourage the more general
use of the free Wassermann tests and other tests available at the Bureau
of Communicable Diseases.

EDUCATIONAL

1. To issue printed pamphlets, cards and placards of information
relative to the prevention of venereal disease, and to coéperate with
the army and navy and other agencies in giving talks to appropriate
groups.

2. To codperate with the Military Welfare Commission in the sup-
pression of prostitution as the principal source of venereal diseases,
but avoiding confusion of the campaign against venereal diseases with
the movement against vice as a strictly moral issue.

3. To oppose any local plan for licensing prostitution or issuing
certificates of health to prostitutes, by showing that this is in conflict
with modern methods of control of venereal diseases, and to substitute
the above program, which is entirely consistent with the suppression
of prostitution.

The Bureau has its main office in San Francisco and a branch
‘office in Los Angeles. As director, the Board secured the serv-
ices of Dr. H. G. Irvine, a specialist in syphilis and dermatology
and a member of the faculty of the University of Minnesota
Medical School. With Dr. Irvine are associated two sanitarians
with medical degrees, Dr. Ethel M. Watters, of San Francisco,
and Dr. Walter M. Dickie, of Los Angeles. Miss Marian Lynne
was appointed Social Service Director. It must be kept in mind
that the Bureau has the codperation of the laboratories of the
Bureau of Communicable Diseases, of the six state district
health officers, of the attorney and the executive officers of the
Board, and of the many local health officers. The district health
officers of the State Board of Health were instructed to place
venereal disease control ahead of all other lines of work.

The Bureau, of necessity, must at first concentrate its work in
the vicinity of the camps and the largest cities, but its field is the

PROGRAM FOR PREVENTION OF VENEREAL DISEASES 31

entire state, and its activities have already reached many of the
smaller cities far from the large military camps.

From the first the health officers were ready to codperate, but
they demanded specific instructions. As soon as possible the
State Board of Health prepared and adopted a set of regulations
with the force of law for the prevention of syphilis and gonococcus
infections. These are printed in the Monthly Bulletin of the State
Board of Health for November and also published for distribution
as Special Bulletin No. 24.

These regulations require the reporting of cases and the compul-

‘sory distribution by physicians to patients of approved pamphlets

(available from the Bureau). The regulations also state the
powers and duties of health officers. Rule 5 on the investigation
and control of cases is lengthy; but of such importance that I

_ shall include it here.

Ruts 5. Investigation and Control of Cases,

All city, county and other local health officers are hereby directed to use every
available means to ascertain the existence of, and immediately to investigate,
all reported or suspected cases of syphilis in the infectious stages and gonococcus
infection within their several territorial jurisdictions, and to ascertain the sources
of such infections.

In such investigations said health officers are hereby vested with full powers
of inspection, examination, isolation and disinfection of all persons, places and
things, and as such inspectors said local health officers are hereby directed:

(a) To make examinations of persons reasonably suspected of having syphilis
in the infectious stages or gonococcus infection. (Owing. to the prevalence of
such diseases among prostitutes, all such persons may be considered within the
above class.)

(b) To isolate such persons’ whenever, in the opinion of said local health -
officer, the State Board of Health or its secretary, isolation is necessary to protect
the public health. In establishing isolation the health officer shall define the
limits of the area in which the person reasonably suspected or known to have
syphilis or gonococcus infection and his immediate attendant, are to be isolated,
and no persons, other than the attending physicians, shall enter or leave the area
of isolation without the permission of the health officer.

{c) In making examinations and inspections of women for the purpose of
ascertaining the existence of syphilis or gonococcus infection, to appoint women
physicians for said purposes where the services of a woman physician are requested
or demanded by the person examined.

(d) In cases of quarantine or isolation, not to terminate said quarantine or
isolation until the cases have become non-infectious or until permission has been
given by the State Board of Health or its secretary.
32 SOCIAL HYGIENE

Cases of gonococcus infection are to be regarded as infectious until at least
two successive smears taken not less than 48 hours apart fail to show gonococci.

Cases of syphilis shall be regarded as infectious until all lesions of the skin or
mucous membranes are completely healed.

(e) Inasmuch as prostitution is the most prolific source of syphilis and gono-
coccus infection, all health officers are directed to use every proper means of
repressing the same, and not to issue certificates of freedom from venereal dis-
eases, as such certificates may be used for purposes of solicitation.

(f) To keep all records pertaining to said inspections and examinations in
files not open to public inspection, and to make every reasonable effort to keep

secret the identity of those affected by venereal disease control measures as far _

as may be consistent with the protection of the public health.

The program has met with results beyond our first expectations.

The reporting of venereal disease cases has improved more
rapidly than heretofore owing to the increased interest. Ex-
clusive of the reports from the military camps, the number of
cases of gonorrhea are about 300 per month, a five-fold improve-
ment in reporting in one year. Cases of syphilis are reported
about three times as well as last year, and about 150 cases are
reported each month.

The cities and counties of California are doing their part in
splendid fashion. In San Diego the County Hospital was found
inadequate to meet the requirements for the isolation and treat-
ment of venereal disease cases. To meet this situation the city
and county are now constructing jointly a special isolation
hospital.

The venereal disease rate at Camp Kearney, twelve miles from
San Diego, has been reported in the Journal of the American

| Medical Association as being unusually high. At first this led
me to fear that conditions in San Diego were worse than they
appeared to be, and that adequate results were not being ob-
tained by the preventive measures. I was reassured, however,
by a report recently received from the camp through the County
Health Officer. Out of 206 cases of gonorrhea in soldiers, reported
during the week ending December 1, only 14 had begun to show
symptoms within a month; 34 cases were of two months’ standing,
113 cases, over half of the total number, had been contracted six
months ago or earlier; and 88 cases were of at least a year’s
standing. If these figures are truly representative of the con-

PROGRAM FOR PREVENTION OF VENEREAL DISEASES 33

ditions at the camp it would appear that these men were infected
as the result of the lack of venereal disease control in the civil
population and the National Guard during past years, and that
the apparent high venereal disease rate at Camp Kearney is due
to a commendable thoroughness on the part of the army surgeons
in searching for chronic gonococcus carriers.

The necessity for careful investigation before conclusions are
drawn from the evidence was shown also by another instance,
The army reported to us for investigation an excessively high
venereal disease rate in a camp near a small town, on the sup-
position that clandestine prostitution must be flourishing there.
Through the courtesy of the post surgeon I was permitted to
assist him in questioning the infected men, and we learned that
none of those seen had been infected in the neighborhood. Some
had been infected in cities hundreds of miles away, and practi-
cally all of them by professional prostitutes. Some of the eases
were chronic, and one dated back to the encampment of the
National Guard on the Mexican Border. These experiences
illustrate the facts that scientific investigation and study are
absolutely essential to efficient control measures, and that state
bureaus of venereal diseases and local health departments
should carry on extensive epidemiological investigations in
venereal diseases, just as they do in much less important diseases,
such as typhoid fever and diphtheria. .

In San Francisco the Health Department, under the able
direction of Dr. W. C. Hassler, has worked out many of the
difficult details of the problem of a large city in close contact with
important military and naval posts. At the beginning of the
work the city set aside a splendid ward in the modern San Fran-
cisco Hospital, of which Dr. R. G. Brodrick is Superintendent.
Next, an examining room in the Hall of Justice was obtained.
Dr. J. A. Sperry, a specialist in gynecology and a member of the
faculty of the Stanford University Medical School, took charge
of the examining clinie and assumed general control of the fol--
low-up work. By arrangement with the police judges all cases
held for offenses related to prostitution are being examined be-
fore their cases are heard. Wassermann tests and microscopic.
34 SOCIAL HYGIENE

search of specimens for gonococci are included in the examination.
Highty per cent of the women examined are being found to be
infected.

All cases of syphilis showing lesions, all cases showing gonococci
or lesions of gonorrhea, and all cases of chancroid, are sent to the
San Francisco Hospital for isolation and intensive treatment
regardless of whether the court imposes a sentence or not. They
are isolated only on the authority of the health officer and under
the health laws and ordinances. Cases of syphilis showing no
evidence except a positive Wassermann reaction are allowed to
be treated by a clinic or a physician approved by the health
department, as are also cases requiring follow-up treatment after
dismissal from the hospital. In all such cases an agreement is
signed by the patient and the clinic or physician. The patient
is required to abstain from exposing others through the practice
of prostitution, and if it is found that the parole has been violated,
the patient is arrested and again placed under isolation and
treatment, but it is proposed to impose a jail sentence in such
cases and to give necessary treatment during the imprisonment.
All cases on parole are required to report in person to the examin-
ing physician of the health department at least monthly, and
final discharge is to be made by him only.

To make such a system practicable it is necessary to do social
service work looking to the rehabilitation of the prostitute, and
more particularly to securing profitable employment, so that she
can abstain from her dangerous calling.. Local workers and
societies are being organized by the Social Service Director of the
Bureau of Venereal Diseases. A local social service worker is
always present in the San Francisco Women’s Court to advise
with the judge and to take over suitable cases referred to her for
the securing of employment. Another line of social service work
is in connection with the study of cases in the public isolation
wards under treatment, with a view of getting them into legiti-
mate employment after discharge. The problem of the feeble-
minded girl is being taken up, and it is hoped that the capacity
of the state institution for the care of such cases will be enlarged
at once, so that the known feeble-minded girls at large in cities
near the army camps can be segregated and properly cared for.

PROGRAM FOR PREVENTION OF VENEREAL DISEASES 35

In Los Angeles City, money has been allotted to the health
department for free Wassermann tests, an isolation hospital for
venereal diseases, the treatment of prisoners for venereal diseases,
an enlargement of the free evening clinic, and codperation in the
remainder of the program. Jos Angeles County has just set
aside $3600 for the next six months for the maintenance of a
Division of Venereal Diseases in the office of the County Health
Officer, Dr. J. L. Pomeroy. Solano and Marin counties have
each pledged five beds in private hospitals for the isolation of
cases, and Sacramento County has set aside a cottage containing
eight beds. The city of Sacramento has accepted a program
similar in essentials to the San Francisco program, and is now
organizing the work. Many other cities and counties are at
present laying similar plans under the guidance of the Bureau of
Venereal Diseases.

The repression of prostitution through the closing of recognized
houses of prostitution and the enforcement of laws against solicit-
ing, strike at the largest source of venereal disease by making
prostitution less accessible, thus minimizing the number of ex-
posures to infection. Without repressive measures the remainder
of the program becomes a Herculean task and is in danger of
becoming dependent on the codperation of the very agencies
which are most responsible for the spread of venereal diseases.
In San Francisco the police judges agreed, about a month ago,
to give stiff jail sentences in prostitution cases, with the under-
standing that in appropriate cases, instead of immediate Jail
sentences, employment and supervision would be secured through
social service agencies. The word went out, and the effect has
been remarkable. Street walkers have almost disappeared. An
additional ward is no longer needed in the San Francisco Hospital,
while a month ago the capacity of the existing isolation ward was
insufficient and plans were being initiated for doubling the num-
ber of available beds. Moreover, in spite of an active Morals
Squad under Lieutenant Goff, the number of arrests have fallen
off rapidly, and for the first time since the Women’s Court was
created, over a year ago, a day has passed without a single arrest
for a charge related to prostitution. I am convinced that there
36 _ SOCIAL HYGIENE

has been a great improvement, and that a fall in the venereal
disease incidence in the civilian and military population will
result. It was Police Judge Morris Oppenheim who started the
new era in the Women’s Court and demonstrated that repressive
measures are entirely practical if combined with efforts at
rehabilitation and humane treatment for disease.

The establishment and accrediting of venereal disease clinics
by the Bureau of Venereal Diseases is intended to make adequate
treatment available to every one at the important centers of
population. Very few existing clinics in the country have a
proper attitude toward the patient and sufficient interest in the
public health. Inspection of clinics and the issuing to the public
of a list of those that qualify will be a stimulus to the institutions
to reach the standards set. Eight clinics and hospitals have been
temporarily accredited and are entitled to receive free salvarsan
from the Bureau of Venereal Diseases. Social service work is
required of accredited clinics, as it is only through careful follow-
up work that patients can be kept under treatment and disease
among their families discovered.

The Bureau is purchasing salvarsan and issuing it free to all
accredited clinics and hospitals, and also to health officers for
the treatment of all cases under isolation for syphilis.- The
object of this free distribution is to render cases of syphilis non-
infectious as rapidly as possible’ Salvarsan is not issued for late,
non-infectious cases. The expense of the distribution of salvar-
san on this basis has not been as great as was expected. It
takes time to bring about the adequate use of this valuable
material. In September and October, the Bureau issued only
243 doses.

The educational program of the Bureau of Venereal Diseases
is slowly getting under way. The Monthly Bulletin of the State
Board of Health and the news letters of the Board are giving
attention to the subject of venereal diseases, and the control
work is gradually forcing its way into the columns of the news-
papers.

The Bureau has issued a booklet for distribution by physicians
to patients having gonorrhea and syphilis, and another publica-
tion for physicians relative to treatment and prevention.

PROGRAM FOR PREVENTION OF VENEREAL DISEASES 37

Within the past few days the Bureau has made arrangements
to furnish lecttires, stereomotorgraph, and lantern slides for
use in the army camps in California under the general direction
of the War Department Commission on Training Camp Activi-
ties. This work has been slow in getting started on account of
lack of army funds for the purpose. I hope that state health
departments will in many states take up this important function
and will do it at once, so that the educational work, so permanent
in its results, will not lag behind the rest of the program.

The program I have outlined has been tried, and is working
in California. It is consistent with the very advanced program
of our army. It is receiving the support of the people. I am
not urging its general adoption without change, but I am hoping
that all our western states will do at least as much as California
to protect the army, and to build permanently for the future
welfare of their people. I hope also that California will not
satisfied with the present program, but will use it as yng

point in working out the much better program of thefuture. .