A First Spanish Reader Part 5

(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 pract.i.tioners, 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 att.i.tude 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 a.s.sociation) 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 citizens.h.i.+p 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 relations.h.i.+p. I know myself that one of the results of this Bill, if pa.s.sed 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 pa.s.s 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 antic.i.p.ations 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 pract.i.tioner 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 gonorrha for generations past have been underground.

Under the present system numbers of unfortunate persons either delay calling in medical a.s.sistance 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 pa.s.s 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 pract.i.tioner 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 s.e.x and occupation of the patient and the nature of the disease, but shall omit the patient's name and address.

"(2.) Every medical pract.i.tioner, 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 pract.i.tioner 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 towns.h.i.+p, 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 pract.i.tioner, and to produce within a time specified in the notice a certificate from such medical pract.i.tioner 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 s.e.xes, 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 prost.i.tution 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 s.e.xual intercourse of married persons one of whom had previously to the marriage contracted syphilis or gonorrha. 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 pract.i.tioner 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 _bona 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 const.i.tute 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 pract.i.tioners 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 cases whose cards showed particulars, 104 consulted chemists in the first place and received more or less treatment from them. He was able to give details of twenty-three cases showing the type of treatment given. In several cases there were severe complications which could have been avoided by proper treatment. There were also cases in which the patient, after taking medicine for a time, had communicated the infection to others. This witness further stated that some chemists charged consultation fees in addition to charges for drugs applied, and in certain cases charges for drugs were made which were little short of blackmail.

The Committee recommend that, in place of section 7 of the Social Hygiene Act, a more comprehensive clause from the West Australian Act be adopted. This is to the following effect: "No person [other than a registered medical pract.i.tioner] should attend or prescribe for any person for the purpose of curing, alleviating, or treating venereal disease, whether such person is in fact suffering from such disease or not."

The Committee would suggest that if the Pharmaceutical Society were to do all in its power to discourage its members from treating these diseases it would have a good effect.

SECTION 9.--MENTALLY DEFECTIVE ADOLESCENTS.

Mr. J. Caughley, Director of Education, stated in evidence: "From a general inquiry made by the Department a few years ago it was ascertained that there were at least six hundred or seven hundred mental defectives in New Zealand under the age of twenty-one. I need scarcely point out the moral danger to the community of so many of these defectives being at large. In particular, the girls are a source of danger to themselves and to the community, since they have little or no will-power or sense of restraint. I am of opinion that all such cases should be registered, and that, unless it can be shown that the mental defective is under thoroughly safe and proper care at home, he should be taken charge of by the State. I am certain that by this means the increasing number of mental defectives would be reduced to a minimum, since mental defectiveness is almost entirely hereditary."

Mr. Beck, Officer in Charge of the Special Schools under the Education Department, cited ill.u.s.trative cases, one of which may be thus stated: "Two feeble-minded parents in New Zealand have had up to the present time ten degenerate children, all of whom are a lifelong burden on the State. Taking the case of these children, and a.s.sessing the cost to the State of maintaining them, the total amount for this family will not be less than 16,000."

The Committee are of opinion that supervision of mentally defective children and adolescents is an important factor in lessening venereal disease, and urge the Government as soon as possible to adopt a system of registration and cla.s.sification of mental defectives, and of segregation where necessary, either in mental hospitals or in special inst.i.tutions where these defectives may be suitably taught, and, where possible, usefully employed to defray the cost of their maintenance.