The Promotion of Social Hygiene in War Time
First Lieutenant, Sanitary Corps, U. S. N. A.
If the public interest of America in various social enterprises were to be indicated by a graph it would be found that with the declaration of war some lines of work declined rapidly to zero and others ascended sharply. Only a few, if any, remain at the present time in the same relative position occupied prior to the opening of hostilities. It will be remembered that in 1914 when the world was thrown into agitation by the beginning of the present war, one social agency after another went to the wall for lack of financial support. A few organizations saw phenomenal growth, for example, the Red Cross and the Y. M. C. A., but there was a general consolidation and elimination among most social organizations.
An even more marked process of elimination took place with the entrance of the United States into the war. Apparently, the criterion of public support is the answer to the question "How will this organization help win the war? " :Unless the answer shows obvious and substantial contribution to the successful prosecution of the war, funds for its support are not forthcoming. This is sometimes most unfortunate and short-sighted, as in the case of social settlement houses, the work of which is of the greatest value to the community; yet American settlements have had the utmost difficulty in continuing their activities and have in most cases survived only by greatly curtailing personnel and services.
In 1914 there was doubt whether social hygiene organizations could continue, while on every hand other organizations were being cut off from financial support. The most important national agency for the promotion of social hygiene had just completed reorganization when the conflagration threatened to sweep it away with the rest. In the face of this danger the board of directors determined to expand rather than diminish the work of the organization, making a bid for support on the basis of national welfare. In the light of subsequent events it is plain how fortunate it is that social hygiene work was continued and expanded, for had it been
(179) discontinued in 1914 the remarkable developments in 1917 and 1918 would not have been possible.
Between October, 1914, the time of the momentous decision by the American Social Hygiene Association referred to above, and April, 1917, the social hygiene movement in the United States developed steadily, if not rapidly, the most substantial gains being reflected in the change of public opinion regarding the control of prostitution and the reduction of venereal disease. Investigations, experiments, demonstrations and public education gradually molded the attitude of leaders in public affairs from hopelessness to hopefulness and willingness to try the newer and more scientific methods. As it became more and more apparent that the United States must enter the war the liveliest interest became attached to the problem of venereal disease and military efficiency. Reports from Europe re-emphasized that which every student of social hygiene knew, that venereal disease is the greatest cause of military disability aside from the casualties of the line and that after-war sequelae are of great social consequence.
After Congress declared a state of war to exist, the attention of leaders of social hygiene in the United States was focused on Washington. The early adoption by the United States of a scientific and comprehensive policy for the dealing with prostitution and venereal disease was a necessity if the United States was to avoid the disasters incurred both by our Allies and our enemies. Within a week after war was declared a notable group of physicians, sociologists and economists met in Washington and adopted a set of resolutions which formed a platform to be recommended to the government as a basis of policy. These resolutions as finally adopted by the Council of National Defense were as follows:
WHEREAS, venereal infections are among the most serious and disabling diseases to which the soldier and sailor are liable;
WHEREAS, they constitute a grave menace to the civil population;
Therefore, the Committee on Hygiene and Sanitation of the General Medical Board of the Council of National Defense, recommends that the General Medical Board transmit to the Council of National Defense for the guidance of the War and Navy Departments the following recommendations:—
1. That the Departments of War and Navy officially recognize that sexual continence is compatible with health and that it is the best prevention of venereal infections.
2. That the Departments of War and Navy take steps toward the prevention of venereal infections through the exclusion of prostitutes within an effective
zone surrounding all places under their control, and by the provision of suitable recreational facilities, the control of the use of alcoholic drinks, and other effective measures.
3. That the said Departments adopt a plan for centralized control of venereal infections through special divisions of their medical services.
4. That the said Departments consider the plan of organization herewith attached.
WHEREAS, the use of alcoholic beverages is generally recognized as an important factor in the spread of venereal disease in the army and navy; and
WHEREAS, these diseases are among the most serious and disabling ones to which soldiers and sailors are liable;
Therefore, be it resolved that we endorse the action of the army and navy in prohibiting alcoholic beverages within military places in their control and we further recommend that the sale or use of alcoholic beverages be prohibited to soldiers and sailors within an effective zone about such places.
Following upon this statement of policy two important events took place. The government put the policy into operation as a practical and workable plan, and state and city governments and civic organizations all over the United States adopted supporting resolutions adding clauses which offered unlimited backing for the stand taken by the Council of National Defense. Nothing that the war has caused to transpire in America has been more phenomenal than the wholesale adoption of a modern scientific social hygiene program by federal and local governments and no program has been given more unanimous and pronounced support. The program itself would have seemed, a few years ago, too elaborate and intricate for consideration as a national undertaking, but under the stimulation of the war not only is the federal government's program in full progress, but state and city governments, civic and industrial organizations, public and private agencies are adopting coordinate measures for the promotion of national health and efficiency. As adopted by the Surgeon General of the Army this social hygiene program is as follows:
PROGRAM OF ATTACK ON VENEREAL DISEASES
An outline of activities and cooperating agencies planned to reduce the prevalence of the venereal diseases.
Methods of attack upon venereal diseases divide themselves into four classes:
A. Social measures to diminish sexual temptations.
B. Education of soldiers and civilians in regard to venereal diseases.
C. Prophylactic measures against venereal diseases.
D. Medical care.
A. Social Measures to Diminish Sexual Temptations
(1) The repression of prostitution and the liquor traffic.
(2) Provision of proper social surroundings and recreation.
These activities which have to do with social matters largely fall outside the jurisdiction of the medical service of the army, but this service can render these activities more efficient by stimulating and supporting them, and wherever practical such support should be given.
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B. Education of Soldiers and Civilians
(1) For Soldiers: a. Lectures; b. Pamphlets; c. Exhibits:
a. Lectures to soldiers should be given by medical and line officers and by competent volunteers furnished by outside agencies under invitation and direction of the Medical Department. These, beside inculcating continence, should explain the risk and waste of venereal diseases and the program adopted to avoid them. Lecturers without authority should not be permitted.
b. A pamphlet should be given the soldier as soon as possible after enlistment. This pamphlet should be very brief and should warn the soldier of the venereal dangers to which he may be exposed and give him instructions, if lit should be exposed, to report as promptly as possible to his regimental infirmary.
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c. Exhibits, such as the Coney Island exhibit, and other exhibits and demonstration methods worked out by the American Social Hygiene Association, the exhibit of the National Cash Register Company, the exhibits of the Oregon Social Hygiene Society and the Missouri Society, should be adapted to the needs of military life and furnished to each cantonment.
(2) For Civilians:
In the attack upon the venereal problem, it is highly desirable that such educational activities as those outlined above for soldiers should be stimulated for the civilian population.
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C. Prophylactic Measures
Instruction in Prophylaxis:
Soldiers should be informed of the fact that there are prophylactic measures that reduce the dangers of venereal infection. But this instruction should take particular care to inform them that there are limitations to such prophylactic measures and that they furnish only partial protection and in no sense give freedom from risk.
The provision of prophylaxis (early treatment) in regimental infirmaries, which should be open day and night, is imperative in any sane attack upon venereal diseases.
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Infirmaries in Civil Centers:
In cities, where there are no adequate civil dispensaries to be used and through which soldiers in considerable numbers pass, either while on leave or in travel, there should be provided in accessible locations regimental infirmaries.
Leaves of Absence:
In the interest of health, long leaves of absence for soldiers should be as far as possible discouraged. Leaves of absence of more than twenty-four hours are particularly dangerous, and it would be advantageous if leaves of absence were timed from as early an hour in the day as possible.
D. Medical Care
There should be a special service in each cantonment hospital to care for skin and venereal diseases.
Instruction in Venereal Disease for Medical Officers:
One of the important functions of these services will be to train a group of men in venereal diseases. The service will, if well conducted, rapidly develop the knowledge of these diseases among medical officers.
The cantonment hospitals should have under their care all cases of venereal diseases which are in the acute, infectious stages. These include:
All cases of acute gonorrhea.
All cases of syphilis during the early infectious stage and which have chancres, mucous patches, or condylomata.
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The syphilitic register of the army should be carefully and fully kept and social facts of epidemiological importance should be secured in every case if possible.
An effort should be made to standardize in a general way methods of treatment, and provision should be made for some special instructions in venereal diseases for all medical officers who have charge of troops. To this end, a manual of instructions should be issued to each of the medical officers in the army. This should especially emphasize the great importance of early diagnosis and treatment in venereal diseases and outline suitable methods of treatment.
There should be furnished cards of brief instruction to patients with gonorrhea or syphilis.
Laboratory facilities are necessary:
1. For demonstrating gonococci and other bacteria.
2. For demonstrating spirochetes by dark field illumination.
3. For urinalysis (which should be required once a week for every syphilitic patient under treatment).
These laboratory facilities should be in the wards of the venereal service.
4. For Wassermann tests.
These to be in the general laboratory.
In order to keep up a high standard of effectiveness, there should be provision for inspection of these services by special inspectors in venereal diseases from the surgeon general's office. These inspections should cover each of the four classes of attack specified.
WM. ALLEN PUSEY
FRANCIS R. HAGNER
GROVER W. WENDE
HENRY H. MORTON
WILLIAM F. SNOW
Committee on Venereal Diseases.
COLONEL F. F.
In charge, Division of Infectious Diseases.
Published by permission of the surgeon general.
Obviously the government's part in such a program requires elaborate machinery, and that such machinery has been constructed and placed in effective operation within the period of one year is one of the remarkable feats of the war. The Medical Department of the army, the Bureau of Medicine and Surgery of the navy, the Public Health Service, the General Medical Board of the Council of National Defense and the War and Navy Departments Commissions on Training Camp Activities are the principal federal agencies which work on this program. They receive expert assistance in making the program most effective from the American Social Hygiene Association, and such other organizations as the American Red Cross, the Y. M. C. A., the American Playground Association and numerous other national and local organizations are lending support and aid. Among all these government and private organizations there is the most intricate inter-relation and, of necessity, the closest cooperation. In addition all are cooperating with city and state governments in carrying out the details of the work.
It would be impossible in so brief a résumé to describe all the special features and penetrations of war-time social hygiene work. Only the most outstanding general facts may be given as indicative of all that is being done for the protection of the health and morals of men in the army and navy, in factories, shipyards and offices, and of women and girls at home and employed.
Wholesome recreation has long been an important feature of the social hygiene program. The healthful occupation of the body and mind is the first line of defense against vice and disease. It is furthermore a necessity for the maintenance of high morale in the civil population and in the army and navy. The War and Navy Departments Commissions on Training Camp Activities are the agencies responsible for providing this safeguard to health and character and, in discharging this duty, provision has been made for the men in every important military and naval establishment and in the communities about such establishments. The American Playground Association, the Y. M. C. A. and other organizations are cooperating with the Commissions in providing recreation. Also special attention is given by the Commissions and such organizations as the Y. W. C. A. to the women and girls in the vicinity of army and navy training camps. Athletics, music, theatrical performances, motion pictures, dancing and numerous other forms of recreation are available for men and women who wish or can be induced to take advantage of them. The American Library Association cooperates with the Commissions in providing abundant reading matter in all camps.
The provision of wholesome outlets would not accomplish its maximum result unless degenerative influences were removed. Vice repression and the restriction of the liquor traffic are the necessary complements of recreation. Legal instruments were early provided by Congress for the repression of prostitution and the sale of alcoholic beverages to men in uniform. The secretaries of war and the navy, being responsible for the application of these legal instruments, assigned the duty of stimulating the enforcement of federal, state and city law to the War and Navy Departments Commissions on Training Camp Activities. The latter, with elaborate assistance in personnel from the Surgeons General of the Army and the Navy, have accomplished remarkable results in the performance of this task. More than eighty red light districts
(185) have been closed. Prostitution and illicit liquor trafficking have been made less available and more hazardous and difficult to carry on. There is not now a single segregated vice district in the vicinity of a military or naval establishment in the United States. In carrying on this enormous task the personnel, experience and facilities of the American Social Hygiene Association are in use by the government. Local law-enforcing officials have cooperated in making the cities of the United States cleaner than they ever had been in their previous histories.
An elaborate educational program has been placed in operation by the combined efforts of the Surgeons General of the Army and the Navy, and the Commissions on Training Camp Activities. The desideratum is that every man should have sane and practical information regarding the nature of venereal diseases, how they are contracted and how they may be avoided. The Commissions, with the assistance and at the request of the medical branches of the army and navy, have approximated this desired end. More than a million and a half pamphlets on social hygiene have been placed in the hands of soldiers and sailors, more than a million soldiers and sailors have heard an illustrated lecture on the nature and prevention of venereal disease, and every large military and naval establishment in the United States has been equipped with exhibits and stereomotorgraphs for graphic instruction. Trained noncommissioned officers are in charge of these facilities, ready to give assistance and advice to all inquirers. Prior to the initiation of this work by the Commissions on Training Camp Activities much had been done by the medical officers of the army and navy in giving soldiers and sailors instructions regarding venereal disease. Their work has been continued and supplemented by the facilities provided by the Commissions.
Recently created sections of the Commissions are making substantial progress in presenting the facts of social hygiene to men and women in industries, clubs, churches; and through the daily and periodical press. Civilians are being informed by lectures, pamphlets, exhibits and newspaper articles of their responsibility for the health and morals of the men in uniform and are having brought home to them the menace of venereal disease as a cause of
(186) inefficiency in industries. Never in the United States in any field of public health or social work has so comprehensive a program of education been undertaken as that which now has for its object the conservation of the moral and physical forces of the nation for the winning of the war. Cooperating with government agencies in the field are the Y. M. C. A., the Y. W. C. A., the American Red Cross, the American Social Hygiene Association and numerous local clubs and societies.
When, in spite of all safeguards of the government and of volunteer agencies, men in uniform expose themselves to venereal disease, medical measures are provided by the medical branches of the army and navy for the prevention of infection. In the past this medical prophylaxis was provided only inside army and navy establishments, but with the present greatly enlarged personnel it is necessary to have supplementary stations in the larger cities to which men go when on leave. Early treatment stations have been established in many of the cities near important army camps. Here soldiers may receive medical treatment and advice which may not only prevent infection but may also re-enforce moral stamina so that exposure in the future may be less likely. Under present circumstances the medical part of this military measure is not possible or expedient for civilians; but it is necessary for the fighting efficiency of our forces.
Men in the army and navy receive better treatment for venereal disease than they would in general were they still in civil life. The medical branches of the army and navy include expert personnel for the treatment of venereal infections, and medical equipment for the proper administration of such treatment. One of the outstanding facts recently brought to light by statistical studies in the office of the Surgeon General of the Army is the fact that five-sixths of all cases of venereal infections reported by the army since our mobilization were acquired by soldiers prior to their coming under military control and discipline.
Even more significant, however, is the work which is being done as a war measure for the treatment of venereal disease among civilians. During the past year eleven state boards of health have established special bureaus of venereal disease with appropriations in each case ranging at about $30,000. These bureaus have for their object the treatment of venereal disease, the education of the public with reference to the seriousness of venereal infection, and the prevention of infections by the enforcement of law and the pro-
(187) -tection of delinquent and dependent persons. The U. S. Public Health Service, in cooperation with the Surgeons General of the Army and Navy, the American Red Cross and the American Social Hygiene Association, has established in cantonment cities, twenty-five clinics for the treatment of venereal disease. Here is available not only excellent treatment and social guidance but also educational material and advice for the well and the diseased. Furthermore, thirty-two states have requested the expert assistance of the U. S. Public Health Service in initiating campaigns against venereal disease.
The net results of all the medical, educational and social measures cannot better be epitomized than by saying that the young American is safer from venereal disease in the army and navy than he would be at home. On the other hand those remaining at home are now safer than they have ever been in the previous history of the United States. Never before has anything so nearly approximating adequate care and precaution been provided to the military and civil population of this country for the prevention of venereal infection, and treatment thereof.
Major General William C. Gorgas, the Surgeon General of the Army, says:
The greatest credit item which the army medical corps has placed upon the war ledger, in the six months that the men have been in camp, is the prevention of some 13,000 cases of venereal disease. This is the number of men who would have had sex maladies, gonorrhea or syphilis, had they stayed in civil life, and who have remained healthy and fit only because we went to war.
This figure is conservative; reckons only our advance, in the conquest of this disease, over the army conditions of peace times. If civilian figures were available, the credit would be greater. Among new men entering the army, we always find a much larger percentage of infection than among seasoned soldiers. In a recent report from twenty-nine representative camps, 83 per cent of the venereal cases were incoming men. In preventing these diseases, we are also preventing their horrible after effects.
Our measure of success in stamping out venereal disease has come from compulsory education in the army, from medical treatment, disciplinary measures, and from community cooperation. The army rate for peace times, although it was a gratifying reduction from civil rates, still was higher than our present figure because of the indifference of the public.
Community sources of infection were not within the control of our medical corps. Now that the army is growing to millions and every family or so has a son in it, we find it easier to arouse interest. Sources of infection are being wiped out, prostitution suppressed, alcohol prohibited, education on the subject pro-
-moted, and wholesome recreational facilities provided in camp and community. Imperfect as are our results, they represent, as far as we can tell, the beat ever yet obtained in any part of the world. They come from only six months for organizing the proper machinery and another six months for installing it in camp and community. The next six months should make a still better showing.
Eight hundred cases of alcoholism have been cured during our camp experience. This is another condition that comes to us from civil life when the men are drafted. These men may backslide at some future time, when they are released from military supervision, but for the time being, at least, eight hundred lives have been rendered normal and temperate.
While this is an item on the credit side of the war ledger equivalent to a great military victory, it is in addition a gain which will have effect not only upon this war but upon the entire future of America. One great American pathologist advances good evidence to show that we are still suffering from the deleterious effect of the great increase in syphilis following the Civil War, effects which must be regarded as one of the expenses of the war. The country that sends the largest proportion of men home from the battles of this war clean and healthy will be the victor when the balance is struck fifty or one hundred years hence.
Today three events of enormous importance are transpiring without smoke or noise, hardly appreciated in their significance for the future. First, soldiers and sailors are learning the real facts about sex health and are preparing to be more intelligent parents. When the boys come marching home they will know more of the scientific and practical facts of sex hygiene than any similar group of men in the 'world and they will pass on to the next generation wholesome and sane information regarding healthful living. Second, our army is making the lowest record for venereal disease that has been made in its history and, what is more significant, the lowest of any mobilized army of the present day in the world. This means that our men are today not only more efficient fighters, but, even of greater importance, they will, upon returning to their families and communities, contribute less damage to the race than would have been possible had the United States not asserted itself for their protection against our most subtle enemy. The long trail of disease, dependency and crime will not follow our men after this war as in the wake of wars of other times. The social gains thus achieved can scarcely be conceived. We have no scale with which to measure the distress and the burdens which we trust will thus be escaped.
(189) Third, our civilian communities are making progress in the education, legal and medical aspects of the program. There is a determination to wipe out venereal disease as a barrier to victory and to make and keep our communities safe for soldiers and sailors. Men and women are living in cleaner towns, are learning more about health, and are receiving better treatment for venereal disease than ever before, and this in spite of the fact that we are at war, or perhaps one should say, because we are at war. The load of mental and physical disease that will be avoided by these measures can only be overbalanced in importance by the additional positive gains that can be made in still further reducing vice and disease below its ante-bellum degree of prevalence.
It is, however, a time for work rather than for congratulations. We must maintain and improve our gains. War for us has just begun and the burdens are only just beginning to be felt. Our achievements are good but are not the best possible. Of this every one concerned feels certain. That army and navy which is the least syphilized will, other things being equal, win; and the nation which controls and dries up the race poisons of venereal disease has the best chance of surviving during the coming ages. The fight against venereal disease is a long campaign for a clean bill of health for the children and grandchildren of the boys now in the trenches.