§ LORD WINSTER rose to ask His Majesty's Government what is their policy in relation to venereal disease, and to move for Papers. The noble Lord said: My Lords, I feel that there must have been a time in your Lordships' House when the mover of such a Motion as stands in my name upon the Order Paper would have made some apology to your Lordships for introducing a very disagreeable subject. Perhaps it is a sign of the march of events that I feel your Lordships will not consider that any such apology is called for to-day; certainly I should find very great difficulty in offering one. There are, however, two matters which I would like to mention. The first is that I fully recognize that there are many whose attitude in the matter which I am about to discuss is dictated by reasons of conscience derived from moral scruples or from their religious beliefs, and I have no wish whatever to give any offence to those who hold such opinions, even though I find it necessary to speak plainly. The other thing is that I may perhaps quote statistics or opinions relat- 436 ing to the medical profession, and I trust the representatives of that profession will believe that I do so to the best of my ability and in complete good faith, even though they find reasons to differ from me.
§ Venereal disease always increases during war, and the present increase is not so great as it was during the last war, but nevertheless the position is very serious and urgent. This problem affects public life, the future of the race, the man-power question and the general efficiency of the war effort. Before the outbreak of this war venereal disease in this country was decreasing. The position was good as compared with many other countries, but since the war there has been a very marked increase. Last year, during 1941, the new infections of syphilis amongst civilians treated at clinics was 7,300. Experience shows that eight cases of gonorrhea occur for one of syphilis, which would give some 60,000 cases in that same year, a total of upwards of 70,000 new infections during 1941. The figures show that during the war syphilis has increased by 50 per cent. amongst the civilian population, and if we add in the Services the increase is in the neighbourhood of 70 per cent. But I must remind your Lordships, so great is the secrecy which surrounds this matter, that 70 per cent. may well be an under-estimate. In Great Britain we have got to set these figures which I have quoted against the fact that on the basis of admissions to clinics—and it is stated that 90 per cent. of syphilis cases are treated in clinics—the syphilis' rate was halved between 1920 and 1936, and in 1936, it is estimated, the incidence was only, 52 per cent. I think that lends point to the present estimate of 70 per cent. increase.
§ The existing position is that large numbers of men and women are contracting diseases which, if not dealt with, will cause very serious consequences. These diseases leave a terrible long-dated legacy of ill-health, and to-day men and women are suffering and dying from infection contracted during the last war. Venereal disease is very peculiar in one respect, that prevention and cure are so closely linked together as to be almost synonymous terms. Early treatment would eventually lead to virtual elimination. The great obstacle is secrecy. In this matter 437 secrecy is the prime enemy. I feel that the matter is of particular urgency to-day because of the arrival in this country of very large numbers of Service men and women, many of them very young, from the United States, from Canada and from the Allied Nations in some of whose countries notification of such diseases is compulsory. I understand there have already been complaints from the American and Canadian Service chiefs, particularly about London. I feel that we have a duty to these countries in this respect. At any rate Regulation 33B, which has been recently brought into existence by the Ministry of Health, docs show that we are trying to do something.
§ When speaking about Service men and women I should like to say one word about the Merchant Navy. The men of the Merchant Navy are not subject to the same supervision as the men of the Fighting Services. The Scottish Committee of the British Social Hygiene Council recently said that it was very disturbed—here I quote—by "the tragic and dangerous increase in venereal diseases in many parts of Scotland and particularly near the ports." In this matter of the Merchant Navy there also arises another question regarding foreign seamen arriving in merchant ships in this country. There are very few amenities provided in our ports for these seamen, and I feel that that fact has a bearing upon what is reported by the Scottish Committee of the British Social Hygiene Council. I trust very much that the noble Lord who will reply to this debate-will impress upon the noble Lord, Lord Leathers, what might be done in this respect by providing more social amenities for the merchant seamen of foreign countries visiting our ports.
§ It is important to remember that these diseases taken in their early stages can certainly in the case of syphilis be quickly rendered non-infectious and ultimately almost certainty cured. Existing medical knowledge, I am told, is adequate and the facilities for such treatment are ample or at any rate can very easily be rendered ample, but as the existing system in this country outside the very limited scope of the 33B Regulation depends upon voluntary notification and submission to treatment, the diseases remain and increase. Medical officers know who are causing the mischief but they have no power to 438 deal with it. At this point I feel it very important to emphasize that venereal diseases do not always arise from loose habits, but they are often contracted by quite innocent people and often by young babies. A man may infect a completely innocent wife. The fell results of these diseases may be borne by innocent people and by infants. However, I do not want to labour that point unduly because I am the first to agree that hard cases make bad law.
§ But there is no doubt about the seriousness of the diseases. In England in 1915 the recorded deaths place syphilis tenth as a killer. Dr. Osier believed it caused more deaths than any other infection. But the important point to bear in mind about syphilis is that it is a secret disease and medical authorities have to fight it to the best of their abilities without knowing its incidence. In the case of other diseases more or less exact statistics exist. There must be a very great number of unrecorded cases of syphilis. Yet, although this is so—and here I have to go for my evidence to another country—Dr. Parran, Surgeon-General of the United States Health Services, has emphasized the necessity for locating cases early for ascertaining the source and for the tracing of contacts. He suggests that earlier location is essential for rendering cases non-infectious as quickly as possible, to render them non-infective before proceeding with the cure. Dr. Par-ran says as regards cure that delay shows a drop in cures from 86 to 64 per cent. Yet, as I say, syphilis is so largely a secret disease. Ascertaining the source of infection and tracing contacts no doubt present difficulties. In the first place the patient must be protected, but experience shows that when it has been made clear that prevention and not punishment is the object, most patients will give all the assistance that they can in tracing the source of infection.
§ That leads to another important point, the necessity for continuous treatment. Reports from five clinics in America show that only 16 per cent. of syphilis patients persevere with their treatment. The defaulter rate in the United States of America is 84 per cent. The defaulter rate in this country in 1935 was 82.5 per cent. of patients who did not persevere with their treatment. I ask your Lordships to contrast these figures with figures 439 in Sweden, where the defaulter rate was only 2.5 per cent. The importance of these figures is that, as is well-known, syphilis is the great relapser among diseases. That makes continuous treatment all the more important. I do not know the figures for gonorrhea in America. Whereas syphilis is described as a killer, gonorrhea is described as a crippler, making a tremendous strain on the productive energy of the national life, in particular having a great bearing upon sterility, which is of first importance at the present moment because of the figures of declining birth-rate with which we are confronted. Gonorrhea can certainly be very easily cured even if it cannot be made non-infective, but because of the mystery and secrecy which surrounds this subject a great number of victims resort to quacks. It is extremely difficult to get them to come out of hiding and take the safe and easy cure which is available. If it is possible to work back to the source of infection, I understand it is believed that this disease could be eliminated.
§ What is the existing position in this country? The efforts to combat these diseases have been since 1916 based upon persuasion, upon a system of voluntary attendance and free treatment at clinics provided by local authorities under conditions of complete secrecy. Publicity of a certain rather furtive type regarding the need for early and continued treatment has been afforded, and this system met with some success up to the outbreak of the war, but since then progress has been reversed. Now by Regulation 33B compulsion in certain cases has been substituted for persuasion. The Ministry of Health has, I feel, been active and forward in this matter, and has provided increased facilities for treatment since early in the war, while the Exchequer has assisted local authorities in regard to the expense incurred by some 75 per cent. The Ministry of Health has watched the situation very carefully in co-operation with the local authorities and the British Medical Association. I think it would be fair to say that the facilities for treatment in the big towns are now reasonably satisfactory, and I understand that the Ministry, at the present moment, is 440 extending clinics and arrangements for propaganda and education.
§ But there are certain questions in this respect which I would like to ask the noble Lord who, I understand, is going to reply on behalf of the Government. Are the existing clinics satisfactorily and adequately staffed and organized? Are sufficient funds available for their efficient working? I would also like to know if medical education in regard to these diseases is sufficiently up to date. I feel that in this connexion I should point out that the British Council for Social Hygiene have stated that there are large new areas of population which have sprung up because of war work where there are no clinics reasonably accessible. The Council also state that young women are repelled by the title of "V.D. Clinic," and consequently do not attend so well as they should. The Council have further pointed to the necessity for the extension of the number of-trained venereal disease health visitors attached to these clinics to search out contacts. I am told that such visitors as are now operating have performed very useful work in securing continuity of treatment. The question therefore arises how far more of these visitors should be provided. The figures quoted by the British Council for Social Hygiene show that more men attend these clinics than women. I think that that is very unfortunate, and it points to the necessity for improving the conditions relating to women. Generally speaking, the Council feel that there are gaps in the treatment scheme which ought to be filled before compulsion is resorted to.
§ That is what we are doing in this country to meet the existing situation. I think it may be of value to glance for a moment at what other countries are doing. There is compulsory treatment for these diseases in the Dominions, in the United States of America, in the Scandinavian countries, in Russia, in France, in Czechoslovakia, in Turkey, in Cuba, in Nicaragua, in Panama, in Yugoslavia and in Spain. Some of these countries impose penalties for knowingly infecting others and insist upon compulsory examination and treatment. I have spoken of the danger of unreported cases. In Chicago, in a drive which the city authorities recently instituted against syphilis by completely voluntary methods, a blood test of one in every five of the inhabitants was 441 taken. As a result of that voluntary submission to a blood test, 42,000 unreported cases were discovered, and of those 42,000 cases over 1,000 were discovered amongst 148,000 school children. A very large percentage of the cases discovered were in an infectious stage. Statistics, following that drive, show that there was a considerable drop in the figures relating to the disease, and an American health official stated that he believed that the disease can be exterminated in a city of the size, and with the density of population, of Chicago.
§ I quote here again the evidence of Dr. Thomas Parran. He describes syphilis as the "Number one Killer and Crippler." He points out that 40,000 deaths occur annually in the United States from syphilitic heart disease. He states that £6,000,000 per annum are spent on the care of the syphilitic insane. He also states, with all the authority of his position, that he believes that the disease can be eliminated from the United States in one generation. But in reporting 478,732 new cases in the United States in 1939, Dr. Parran says: "Like an iceberg the greater proportion of the menace remains submerged in States where the control programme is new." That relates, of course, to the secrecy which prevails in these matters, and Dr. Parran emphasizes how necessary it is to teach youth to avoid infection. Referring to 518,000 new cases in 1935 he says that probably an equal number of cases went unrecognized or were being treated by quacks. He points cut that many remain ignorant that they are infectious until the disease has passed through the latent stages, and only go to doctors when very dreadful conditions appear and when the chance of cure is far less favourable. These facts, quoted by Dr. Parran in regard to the United States, certainly point the moral here of the evil of secrecy and emphasize the need for education with regard to these diseases.
§ So much then for what has been done in America. Let us look at a country nearer home—Sweden. In that country very great progress has been made. In New York City there were 1,836 cases in one month in 1936. In Sweden with the same population there were only 431 cases in the whole country in 1935. If we look at Scandinavian principles in regard to this matter we find that they are these: All cases must be reported. All cases 442 must take treatment. Free treatment must be available for all who are infected; and patients must go to hospital if necessary. In Scandinavia, people understand all about syphilis. There is no taboo about it. They recognize the necessity for treatment. Our advice notices are placed, as I have said, in very furtive surroundings, but I remember that in Copenhagen they appeared on public hoardings alongside other advertisements. The result of this more realistic outlook is that in 1936 there were only 1,600 cases in the whole of Scandinavia, and in fact in Scandinavia syphilis is spoken of as a rare disease. In Sweden, in particular, great progress has been made in reducing the incidence of it.
§ With regard to the necessity for reporting the sources of infection, I should like to quote certain figures to your Lordships. In Sweden, between 1926 and 1935, 137,563 people were treated for the first time. Of those, 17,480 named the source of the infection, and no fewer than 10,329 of those sources were brought under treatment. The effect is, as I have said, that in Scandinavia syphilis is spoken of as a rare disease, and I think that that is due to the fact that, if we compare the figures in Scandinavia and in this country, we shall see that there is far more sense of secrecy and shame shown here than in Scandinavia, where people are very much more matter of fact.
§ What are we doing to meet this war situation with regard to venereal disease? Regulation 33B has been brought out by the Ministry of Health, and is aimed at a limited but admittedly a very serious aspect of the problem. The powers taken under it are taken as a war-time measure, based on information on war-time conditions which has reached the Ministry. The existing law, prior to the passing of Regulation 33B, was unable to deal with infected persons who refused to be treated and who were spreading the disease. Public health authorities had no power to deal with this type of case, and consequently the spread of venereal disease could not be checked. This matter is of very great importance to Service authorities. I served at Grimsby as Chief Staff Officer for a certain number of months in this war. I was in charge of trawler convoys on the East Coast. Trawlers have very small crews and a very heavy armament.443
§ If any man is unable to go to sea in his trawler on convoy duty, it means that some other man must do his work, and that some portion of the armament of that trawler remains unmanned. I remember at Grimsby that in the course of a week we traced eighteen cases of infection to the same woman. The matter was notorious. The Chief Constable, when appealed to in the matter, said he could do absolutely nothing. I wrote to a member of the War Cabinet about it and I received, in rather more flowing language, the same reply, that nothing could be done about it. That was the situation with which we had to contend in Grimsby.
§ Regulation 33B will enable the medical officer of health to enforce examination and treatment of any person named by two separate individuals undergoing treatment as a source of their infection. It provides fairly severe penalties—a fine of up to £100 and three months' imprisonment—but the Regulation is really merely a loop-hole in the general policy of education and voluntary treatment, and those whom it will bring under treatment will be a very small proportion of those who have proved impervious to propaganda and persuasion. It is hedged about by safeguards. Medical officers of health are enjoined to exercise special care and discretion. They must assure themselves that the information is reliable and, after that, they must do all they can to persuade infected persons to undergo treatment, and only if such persons refuse treatment will compulsion be applied. All the information will be treated as confidential. Compulsion has to be sanctioned by the county or county borough council. When one thinks of all the safeguards, one must admit that the Regulation will be very difficult to administer; nevertheless, in my opinion, the Ministry of Health is to be commended for introducing it. It is certainly a step in the right direction, and various committees who make these matters their concern have expressed their approval of it. The Regulation can operate only, however, when the mischief exists in an aggravated form, and it insists only upon treatment and cure. Is it wrong to insist that people who, with no conscience, are spreading a deadly disease, should be taken out of circulation until they are no longer a danger to the community?444
§ I think it is always a good thing to examine the arguments against a case which one is putting forward. I agree that the Bill introduced by the Edinburgh Corporation in 1928 on the Swedish model, which had in view compulsion to undergo complete treatment until a cure was certified, was defeated in another place. I think that the figures of the voting on that occasion are very interesting; the Bill was defeated by 156 votes to 93. In other words, only 249 votes were cast upon this occasion, which, I think, illustrates how very nervous people are, or were at that time, about expressing an opinion on this matter. I agree also that a Commission sent by the Ministry of Health in 1937 to study conditions in Sweden and Holland did not report in favour of compulsion. They reported against compulsion for four reasons. First of all, they said that compulsion would lead to concealment for fear of exposure. They then referred to the difficulty of its application in densely-populated countries, which would make tracing back to the source of infection very difficult. That is a strong argument, but I think that the evidence which I have quoted from Chicago militates against it. They spoke of the possibility of blackmail, but surely we should be able to control the possibility of blackmail in this matter, and I cannot regard that as a serious objection. Finally, the Commission argued against compulsion on the ground of respecting the liberty of the subject. I feel that the liberty of the subject is a peculiarly weak argument in this respect. What about the liberty of the subject in regard to other infectious diseases?
§ As regards the argument that compulsion would lead to concealment, and that sufferers will not seek medical treatment if it involves notification to a public official, again I quote Dr. Parran, who, out of the fullness of his experience, observes that the actual name of the patient need never be reported to a public official; he says that the initials, the date of birth or a number are sufficient for record purposes, and only if the patient refuses to continue treatment and remains a menace to the community should be forfeit his privacy. The possibility of driving the fact of infection underground can be dealt with by establishing confidence on the part of those infected and by educating them to realize that concealment is 445 an anti-social practice. There are also other objections raised against Regulation 33B from the point of view that it would be ineffective. It is said that it would operate unfairly against women. I do not know why, because 33B applies perfectly equally to men and women; there is no discrimination. The objectors to 33B also say that more and better facilities for local treatment will meet the case. But however much you improve the facilities for local treatment, you are only dealing with cure, and you are net tackling the question of prevention.
§ I consider that these diseases are a social menace. Religious and moral scruples may have operated to weave a cloak of mystery and hyprocrisy about them behind which these diseases have done their deadly work. It is time to strip the cloak aside. These diseases can and should be eliminated. That should be the ultimate aim of Government policy. And to that end a healthy public opinion ought to be created, by education and publicity. Control and elimination should be our aims. The public must co-operate with the health authorities, remembering that apart from all other considerations the cost of elimination will be less than the existing cost of clearing up the wreckage which these diseases leave in their wake. How much are we spending upon research into and treatment of venereal disease as compared with other diseases? This is a matter of public health. Let the public remember that public health is purchasable, and if the public demand it this plague can be stamped out. Education is essential, and removing the taboo on discussion will help the work of education. We have been letting ourselves be ruled by Mrs. Grundy in this matter. I feel that it is time that we faced squarely up to it and looked the facts in the face. We hear much in these days from Sir William Beveridge and from President Wilson about certain freedoms; I do not think that among those freedoms should be the freedom to spread disease and contaminate innocent people and children. I beg to move for Papers.
THE LORD ARCHBISHOP OF YORK
My Lords, I am quite certain that the House recognizes the great importance of this question, and I for one am grateful to the noble Lord for introducing it. He need not have hinted even at the possibility of an apology for bringing 446 this kind of matter before the House. Quite obviously it is a matter which we ought to discuss, and those of us who sit on the Episcopal Benches are the very first to welcome free and open discussion of a matter which affects morals as well as health. In the last war of course this subject was very much to the fore. I was at that time vicar of a great parish in one of the largest of our seaports, and I know how much this matter of venereal disease was in the mind both of the military and civilian authorities. In some ways the position to-day is even more difficult than it was then. Twenty-five years ago the disease was at its worst in a large class of prostitutes unlikely ever to marry or to have children. To-day that class has dwindled in numbers, but instead there are large numbers of women, some of them not much more than girls, who are not professionals, who would never think of taking money, but who, in the exercise of what they regard as sexual freedom, run risks of disease which may have disastrous results both on themselves and on their children when later they marry.
I do not suppose the Government can give us detailed figures showing how far the disease is spreading both in the Services and in the civilian population. I think if they could it would show us that it was affecting classes which hitherto have been largely immune. The reason for the increase of disease in wartime is of course obvious. You have large numbers of young men and young women, full of life and health, well fed, removed away from their homes, far away from family influence and the standards to which they were accustomed in their locality, often bored with their work and still more bored with their leisure, and from time to time some of them under very great nervous strain. These are the pre-suppositions for sexual licence unless there is very definite conviction in favour of self-control. And those who lack self-control are not always those who are naturally profligate; but you do find occasionally young men from perfectly respectable homes who before they joined the Services had kept free from any risk of incurring disease, but whose self-control under the special circumstances of the time has given way; and the penalty which falls upon them as well as upon the man who 447 is profligate is sometimes perfectly appalling.
The House will rightly expect me to approach the problem from the religious rather than the medical point of view, though there need be no inconsistency between the two. I will state the Christian position quite bluntly. It regards promiscuous sexual intercourse as sin, and it uncompromisingly condemns it as such. The Christian Church cannot therefore approve of any suggested remedy which appears either to contradict this teaching or to condone the sinfulness of such intercourse. Its first duty in this matter is to teach continence and self-control. In the Services the chaplains are given opportunities of doing this. I understand too that the doctors in their lectures on sex make it plain that continence and self-control are the surest safeguards against infection. This should be emphasized throughout every lecture and not come in merely as an incidental remark. It will do infinite mischief if young men who come from decent homes find when they join up that it is assumed as a matter of course they will be immoral. But there are many who never hear the religious appeal or, if they hear it, regard it as irrelevant to their every-day lives. There are many, too, who fail to live up to the moral standard which they know to be right.
In a matter which is so gravely affecting the health and life of the nation it is then clearly the duty of the State to supplement the religious teaching of the Church by bringing home to its citizens the personal and social dangers which may arise from promiscuous intercourse. I understand, and I sympathize with, the position of those who shrink from the public discussion of a question which is both medical and moral, but it would be criminal for the State to allow its citizens to remain unaware of the dangers of venereal diseases and of the best methods of treating them. There is, of course, a great deal of vague and uninformed discussion on these matters, not least among the young. I sometimes think that the hackneyed phrase, "a conspiracy of silence," is in our days inaccurate. I felt that the noble Lord opposite was inclined to overrate the amount of silence on the subject. The subject is very widely and generally discussed, but there is usually 448 very little appreciation of the grave results of these diseases and of their contagious character. I suspect there is less than there was after the last war, when there was active propaganda. Familiarity has bred contempt, and there is a widespread tendency to regard these diseases as easily avoided by certain precautions and as easily and simply cured by modern medical science.
It is in the interests, both of the individual and of the community, that these foolishly optimistic views should be shattered. The horrid quack advertisements of some years ago, now rightly forbidden by law, did at any rate, in a very unwholesome way, bring home to the public the dangers of these diseases. The State should undertake itself, or should entrust the voluntary societies with, such a thorough and careful propaganda that all classes of the population except the youngest should be made aware of the consequences of the diseases and of the necessity of immediate treatment if they have been contracted. Literature, the Press, and occasionally the wireless should be used for this purpose. But when instruction is given to the adolescent, I would urge very strongly that it should not be mainly on these diseases, but warnings against them should be given only incidentally as part of the larger instruction on the meaning and right use of sex. I am confident that the Christian Churches would support a bold and wise policy for the enlightenment of the public on these diseases provided it was always made clear that abstention from promiscuity is the most certain safeguard. I do not believe that scientific lectures, literature, still less the appeal to fear, will prove sufficient deterrents when the religious appeal is ineffective, as it will be in some cases. There should always be a moral appeal for the safeguard of future children and for the welfare of the nation.
I would next urge that there should be suitable extension of the clinics for the treatment of these diseases. There are not nearly enough. Often they are out of reach of the sufferer. I should be very grateful if the noble Lord who is going to reply for the Government could tell us how many new clinics have been started since the war began. I should be glad if he could tell us how far these clinics are accessible throughout the country. Often they are far away. 449 They ought always to be a department of a hospital so that those who go to them are not at once recognized as suffering from this disease, as would be inevitably the case if a clinic stood by itself with the title that it was intended for venereal disease treatment. Those who go to these clinics should be treated, as I believe they are, with sympathy and understanding, and encouraged to persevere with the cure. Here I should like to emphasize a point that was made by the noble Lord opposite. It is a most serious matter that so many of those who go to these clinics never complete their treatment. As he says, in this country something like 82 per cent. left before they were cured. By giving up the treatment before he is cured, the patient may endanger his own health, the health of his family, and the health of the nation. While notification is voluntary it is impossible to force him to persevere in the treatment, but much can be done by persuasion, by confidential visits—I know it needs tact and skill—from a social worker connected with the hospital, who will remind the patients of the danger they are incurring by their failure to persevere. I believe that such visits have been undertaken in connexion with one of these clinics in a northern town with considerable success.
Then I would ask the Government—this is another matter—to encourage local authorities to employ more women police. This is not a solution of the problem, but it is a contribution towards its solution. Round a number of military establishments there often collect a number of thoughtless silly girls, who are sometimes a nuisance to the soldiers and occasionally, through sheer foolishness, run into moral danger and later, to their consternation, find themselves suffering from venereal disease. Male police, whether military or civilian, find it extraordinarily difficult to deal with girls of this type. Women welfare workers have not the authority and often, if they offer advice, are merely ridiculed; but the police woman is specially adapted for this problem. She has both the training and authority to deal with this class of girls who are troublesome without being criminal. Experience has repeatedly shown the value of these police women, and the Home Office has already encouraged the local authorities to make more use of them, but the Victorian 450 prejudices of some of the Chief Constables and their watch committees have frequently stood in the way of their employment.
There are two other matters to which I want to make some reference. It is notorious, as I agree with the noble Lord, that one person, through selfishness or ignorance, can infect a large number of people, and at present there is no method by which that person, whether man or woman, can be restrained from doing so. No doubt this is a reason for Regulation 33B, but I am bound to say that I have the gravest doubts about its practical working. I dislike intensely, for instance, the anonymous informer who, out of ignorance or malice, may bring false accusations against an innocent person. The danger of that is much more serious than the noble Lord appeared to realize. I can recall, when I was a vicar, more than one case of a man being threatened with blackmail—sometimes successfully—by some woman. There is a real danger if we are going to have informers who can give their information anonymously. But there also seems to me something absurd and illogical in the position that while a person who is informed against must receive treatment, if found to be infected, the equally infected informers are under no amount of compulsion to receive treatment. I am also very apprehensive of the use which may be made of the so-called clearance certificate. This may encourage a false plea of security, for the person who has received it may be infected again within a few hours.
A much larger question is that of making the notification and treatment of venereal diseases compulsory. Common sense and logic both seem to demand that, if scarlet fever and whooping cough must be notified, the much more serious venereal diseases should also be notified. As the noble Lord has told us, in Sweden notification has been the rule for a quarter of a century with great success. There is also great advantage in the fact that where there is compulsory notification it is possible to insist on the completion of treatment. On the other hand, it is doubtful if at present it would be possible to enforce compulsory notification and treatment in a crowded country like our own. To avoid compulsory treatment there would be a tendency to conceal the disease and to postpone seeking medical advice. I should be greatly interested in 451 hearing what the noble Viscount, Lord Dawson, will say on this. Nothing is worse for respect of the law than that it should be disregarded. This threatens to bring all law, not only the specific law infringed, into contempt. The arguments for and against compulsory notification are therefore strong.
While there is any chance of voluntary action in the way of education and treatment succeeding I should be against compulsory action, but if the disease still increases then it would be the clear duty of the Government to reconsider afresh the whole question, and, if necessary, to consider the application to the civil population of the compulsory notification which is already in operation in the Forces. When once the nation understands the gravity of the position, that the health not only of this generation but of the next generation is at stake, I believe it will be ready to welcome legislation far in advance of anything we have at present for the control and reduction of diseases which cause untold mental and physical suffering. But before there is any possibility of the acceptance of such legislation the Government must let the nation know frankly and plainly the actual facts about the extent of these diseases and of the results which follow from them.
§ VISCOUNT DAWSON OF PENN
My Lords, I do not wish to repeat some of the figures you have already heard, and I will limit my figures to a few. It is the fact that in the ten years prior to the war there was a satisfactory decrease of venereal disease, but since the war broke out there has been a reversal in the trend, and we are now in about the same position as we were in in 1932. There has been an increase of 70 per cent. in the number of cases. The increases are chiefly in the ports. In seven ports, comparing 1939 and 1941, there has been a rise in the figures from 942 to 1,909. There is no doubt, therefore, that the increase is a serious one. Figures which I think are perhaps worth attention show that in practice amongst civilians there has been a steady increase of treatments amongst women—45.9 per cent. in syphilis and 29.3 per cent. in gonorrhea. That leads us to this reflection, that we are not dealing with the same problem as our forefathers were even in the last war.
452 The women who are open to contract these diseases belong to more classes than they used to do. There is obviously a class, a professional class, who gain their livelihood and must of necessity be promiscuous. That class is relatively decreasing. There is a second class in which you have the so-called amateur who gets her own living, who is irresponsible in temperament and sets out to get pleasure from the men who attract her and profits by the amusements they give her. In some respects I think that is the most dangerous class of all. They are more likely to give disease where disease is least likely to be expected. But we must not altogether ignore a third class. There are girls of good repute who no doubt will in future become mothers, who set up friendly relations, which friendly relations embrace sex relations, and I think there is an increasing number—one cannot say how many—of venereal infections arising in those circumstances. It is important to mention that, because directly you get outside certain set classes your problem becomes much more o complex and it is more difficult to tackle. There is one good feature about the increase in the women cases amongst civilians and that is it does show that the women do use the clinics. For myself I am a little doubtful whether the labelling of a place makes much difference in days when these things are discussed more openly than was the case hitherto amongst young people, almost across the table. I do not think we need have much fear if good treatment is provided. If good treatment is provided, I do not think that women, any more than men, will be kept away from availing themselves of it.
Both gonorrhea and syphilis are remarkable for the precise knowledge we possess of their causes, and, equally, for the precise knowledge we have of the treatment which will cure them. A third important feature is this, that they both start as local diseases. They do not produce constitutional effects for some appreciable time after infection takes place and that is one of the many justifications for facing up to this problem squarely. We cannot get away from the facts. We have the facts that the causes are known, that the means of treatment have improved vastly, that those methods of treatment are effective; and, what is more, that the diseases start as local 453 diseases and there is a good chance of catching them up. On the other hand, there is a gloomy side to the picture, because if left alone, if left untreated, these diseases do become constitutional, especially syphilis, and the results may go on for years, almost to the end of life. There is the further difficulty with both these diseases that there is a danger of people who contract them not fully realizing even that they have the disease. They may have it so slightly, and they may be the means, quite unintentionally, of infecting those nearest and dearest to them. even their wives and their children.
These being the facts, what is the way of facing them? We have to admit that there is a large boy of opinion—a diminishing body it is true—which has been opposed to taking too much care for these people. A certain body of opinion says that "a man must suffer for the consequences of his own acts." That was seen in the last war only twenty-five years ago, when there was a proposal to put up preventive ablution centres with the idea that a man who knew he had exposed himself to infection co lid there and then undergo ablution and thereby be saved the infection he might otherwise contract. That measure caused a considerable outcry in the last war, as your Lordships know, and great objection was raised to the setting up of the ablution centres because of the old principle "you must suffer for your own deeds." In a truly British way the problem was solved by altering the title of the clinics, and instead of calling them "preventive clinics" they were called "early treatment clinics." A more characteristically English evasion it would be difficult to imagine. However, it did the trick. It must be said for our Catholic friends that at about the same time the difficulty was referred to Rome, and when Rome had given a sufficient consideration to the question it gave out a brief edict that because a man imperils his immortal soul that is no reason why we should not do the best we can for his mortal body. That, I think, really holds the field.
I cannot myself see how this illness can logically or sensibly be treated except under the Public Health Acts,. treated in same way as other infectious diseases. I have never in all my life, and I am sure no doctor ever bas, found that the fair and considerate attention given to a man or 454 woman's body ever had anything but a good effect on that person's mind. Therefore there should be no hesitation. Anything which promotes efficiency of treatment of these diseases should be received with a favourable eye. Take certain other diseases for purposes of comparison. It has been the custom in this country for public health authorities to take gradually more powers. They have done it in that gradual evolutionary way which is characteristic of this country. Local authorities began by asking permission to require notification of infectious disease, and from that point back in the last century the system has grown so that now there are a certain number of recognized notifiable diseases. Since the Act of 1936 it has been within the power of health authorities to take care of the people affected if they are unable to take care of themselves. If, for example, a person is verminous or suffering from scabies it is within the law for that person to be taken for treatment to a public institution. If a patient is suffering from something of an infectious character inside a factory, it is within the power of a public authority to say that the patient must be put away where he will be safe and can be looked after, and where he will cease to be a trouble and menace to other people.
If that system can be applied to such diseases as typhoid, why in heaven's name should it not be applied in the case of venereal disease? There are two sets of difficulties that we have to meet. The first difficulty is in regard to notification. It is true that up to now venereal diseases have not been notifiable, but that is purely a matter of tactics and expediency. I agree with the most reverend Prelate on the subject of notification. I think that people would be more frightened and would be more anxious lest they should be discovered. That is the opinion of most health authorities. But the question of treatment is different. We. know that, apart from those who are afflicted and go to the clinic and carry out treatment, there is an irresponsible residue of persons—they are not vicious, they are people who are feckless, who live for the clay, in other words who have the faults that brought them to grief—who will play about and be responsible for multiple infections, multiple infections indeed as high as seven and ten. I will give your Lordships two examples. 455 There was one instance in the Forces of a woman who gave infection to no fewer than seven men in succession, and of those seven three were married and their wives became infected. There was another case of a girl who haunted a place having infected no fewer than eight or nine people.
It is that hard core of irresponsibles that must be dealt with. In some way or another they must be got hold of. They cannot be dealt with in the ordinary way. In my judgment Regulation 33B has been most carefully thought out and is the best under the circumstances. Many people may say that it does not go far enough, but you can always take a further step forward. It is no longer an offence, as in the last war, to have intercourse with the opposite sex if you are infected, but it is an offence not to go for treatment, which is a purely personal question. There is this protection that if the doctor as the head of the clinic gets to know, as he does get to know, from his men who are the women hanging about the place, and if suspicion falls upon one or two women from more than one source, then the doctor will report these women secretly to the medical officer of health and it will be for the medical officer of health to take steps with the permission of a justice or of a court of summary jurisdiction to secure compulsory treatment. I cannot think that anything serious is likely to occur in such cases, and at any rate what might occur would be better than letting people spread disease in an irresponsible way when they might be restrained for their own benefit as well as for the protection of the community.
There is one other question with which I should like to deal. That is the matter of preserving secrecy, and not only preserving secrecy but preserving the belief of the people in secrecy. That is one of my reasons for hesitating before compelling notification. I am afraid the effect on the ordinary layman's mind would be to make him think that that would mean publicity. There is an aspect of publicity that concerns our legal colleagues. Since secrecy was promised some years ago in connexion with venereal disease, there have been, I think, three occasions on which secrecy has been thrust aside in a Court of Justice. There was the Guildford case 456 where a man was asked to produce the secret books of a clinic. The Judge in Court always looks more formidable in his wig and gown on the Bench than the gentle demeanour of noble and learned Lords here present, and on all the occasions to which I am referring the doctor was practically hammered into giving away the secret. If only a medical man would put his two feet on the ground and say "I won't do it" it would bring an end to the whole business. I think it is worth our while to consider soberly the general question of medical privilege which is here involved. I remember the late Earl of Birkenhead meeting me one day and saying to me: "I hear you are out for medical privilege." I said: "I am looking forward to the day when we can fight that out on the floor of the House." That day never came, but I recall an interesting episode a little later, when Lord Birkenhead said to. me: "I have come round and altered my opinion. I think a modified privilege would be a right and proper thing." It remains, however, that there have been at least two, if not three, occasions when the privilege of secrecy involved in these cases has been ignored and broken, and the consequences, if repeated, will be very serious. I hope that in some way or other there will be a "come together" on this matter, and that the principles to be observed in regard to this question of secrecy will be made abundantly clear.
I think Regulation 33B is a good step forward. It is a step from which we can go on still further if necessary. I, at any rate, think that it is quite a right and wise Regulation. I agree that we do require more centres, but I would ask your Lordships to remember that the country is suffering from a very grave depletion of the medical profession at the present time—a far greater depletion than was ever anticipated when the war began. Effort has been directed to increasing the number of these centres, but it is obvious that in war-time this cannot be done so expeditiously as in times of peace. But, that the best that can be done is being done, I am quite confident.
§ LORD ATKIN
My Lords, I shall venture to detain you for a few moments only, but there are one or two points which have arisen in this debate to which I would like to refer. First, about compulsion. I am satisfied, and I think that 457 your Lordships must be satisfied also from what you have heard of the prevalence and terrible effects of these diseases, that venereal diseases are really a peril to the State, and that there is no form of belief in liberty which world prevent one from whole-heartedly accepting compulsion if compulsion would cure the State of the evil which threatens it, especially in war, and more particularly when the persons who are especially affected are members of the Forces of the Crown. Therefore, while the most reverend Prelate—very naturally, if I may say so, and everyone, I think, will agree with him—attaches very much importance to moral education, to Christian education in respect to continence and self-control, at the same time, to try mind, the time has plainly come when, in conditions of war, compulsion ought to be applied. And if compulsion ought to be applied it seems to me that provision is made for its application in a very modest and moderate form by Regulation 33B.
I, for my part, can see no objection to the fact that the informers are to have their names kept secret. There is no doubt that you would get no informers at all if you did not make such a condition. Personally I would go much further. First of all, so far as the people concerned are affected, it seems to me that if a woman who is a professional prostitute is found soliciting and is also found to be infected by venereal disease, that is a case in which she ought to be compulsorily treated. Why you should wait until you have proof of her passing on infection to two other people I cannot think. Obviously she is a danger to the community, and as the noble Lord who introduced this Motion said, in what seemed to me a most convincing speech, it is clear that a woman of that kind in a seaport might destroy, for the time being, a whole ship's crew. I see no reason at an, therefore, why you should wait for two informers in a case where a woman suffering from disease has been found soliciting. I think she ought to be subjected to treatment.
I would go much further than that. I do not see why it should not be made an offence for anybody who knows, or has reason to believe,. that he is suffering from venereal disease not to submit himself to medical treatment. To make the necessary provisions for that I think would be quite easy. Obviously anybody 458 who has heard about and knows of the effect of these diseases would know that a man in fact is very unlikely to avoid going to his doctor, and if he does go to his doctor then he would comply with the law. The only condition I would make is one which was referred to by the noble Lord—that is to ensure that if once a man has begun his treatment for venereal disease he is put under a legal liability to go on with it until the treatment is completed. Once he has beep to the doctor or to the clinic it seems to me quite an easy thing to secure that continuity by law. In an instance in which a man was treated for venereal disease and it was found that he had not gone in time for treatment, he would be making himself liable to the publicity which to my mind is the chief sanction in these cases, and he could be dealt with accordingly.
We have heard a good deal about clinics. No doubt these provide the best way of dealing with these diseases. But, as the noble Viscount, Lord Dawson of Penn, has pointed out,. in the past, and, no doubt, at the present time also, a great many people are treated not by clinics but by local medical practitioners, who in most instances, no doubt, are quite experienced in dealing with these diseases, and quite capable of curing them in, at any rate, the simpler cases—cases of gonorrhea, for example. I have said that secrecy, to my mind, is one of the great essentials if you are going to deal satisfactorily with these diseases. For that reason I entirely agree with the criticism that the clinics should not have put over them: "V.D. Clinic." The first essential is that persons who are encouraged to undergo treatment should be enabled to undergo it without betraying to their neighbours the fact that they are undergoing it. That is one reason why I consider it would be very much better to compel a person to undergo treatment either at a clinic or at the hands of his doctor than it would be to institute a system of compulsory notification. Notification is only a means to an end. It is. only a means to getting a person to undergo treatment. If he does undergo treatment that is all the State can possibly require, and the true object seems to me then to be attained.
From the point of view of ensuring secrecy, I entirely sympathize with the criticism made by the noble Viscount, 459 Lord Dawson of Penn, about the compulsion on doctors in Courts of Law to disclose the treatment of a patient for venereal disease, and I have already spoken to the noble Viscount about this. The late Lord Birkenhead held a different view. The noble Viscount, Lord Dawson of Penn, said that Lord Birkenhead did not discuss it in this House, and that may be so; but in his collected papers there is a very animated paper by him controverting the idea that there should be privilege in respect of medical communications. It is most interesting to hear from the noble Viscount that that great Judge eventually changed his point of view.
One of the cases which the noble Viscount, Lord Dawson, mentioned, seemed to me to be a terrible case. It was the case of a man who had gone to a clinic under the guarantee of secrecy given in one of those printed communications which are affixed, as the noble Viscount said, in furtive places—by which he means underground lavatories—to the effect that the treatment would be entirely confidential and would not be communicated to anybody. One of these men, acting upon that, went to a doctor and was treated; but, when the case came before the Courts—it was a matrimonial case, I think—the doctor was told by the judge that there was no privilege, and that he must communicate from what his patient had been suffering. To my mind medical privilege, in circumstances of this kind, is a national necessity, because people will avoid going to doctors if they know that a doctor can be compelled in a Court of Law to disclose the information in his possession. I see every reason for protecting the doctor in regard to communications in that respect. If we can maintain secrecy as much as possible, we shall encourage people to go for treatment. I think that they should be compelled to go for treatment, and I think that Regulation 33B is most valuable; I only wish it went further.
THE LORD BISHOP OF NORWICH
My Lords, I should not have ventured to intervene in this debate, especially in a maiden speech in this House, if it were not. That I have been closely connected with all questions and problems and work to do with sex morality on behalf of the Church of England for a considerable number of years. If I am now critical of the policy of the Minister of Health, and 460 in particular very critical of the new Regulation 33B, it is not from any lack of understanding of, or of sympathy with, his problem; indeed, it is not his problem, it is the problem of the nation. The spread of venereal disease in these last years is truly alarming, not merely from the point of view of the sufferers, the point of view of the immense accumulation of ill-health which could have been avoided, but even more as threatening the health of the nation at large and the health of the next generation. The Minister is surely right in determining that something must and shall be done to meet the new needs and therefore the criticism of many people directed against Regulation 33B—and I should like to emphasize that the opposition is very widespread amongst those who know most about these problems from the social, as apart from the medical, point of view—is directed not against the purpose of the Minister in dealing with this problem but against the particular methods that are proposed. Of these methods, of the content of Regulation 33B, others have spoken, and there is no need for me to deal with this matter at length; but there are one or two points which I should like to emphasize.
First of all, there is the rather horrid emergence of statutory blessing given to an informer, something which is very alien to the general spirit of English law, something much more common in the countries against which we are fighting than in our own. Secondly, there is a very real danger that under this Regulation 33B, which is intended, of course, to bring about a decrease in promiscuous relationships, the result may be an increase rather than a decrease, owing to the very real danger of giving a false sense of security. The contact who has been summoned to a clinic and who has undergone treatment will be given what is called a clearance certificate. That is not a certificate of health; it is merely a certificate that he or she is no longer suffering from venereal disease in a communicable form. Obviously there is nothing in the world to prevent that person having the disease in a communicable form an hour after receiving that certificate, but it is inevitable that other people, seeking promiscuity, will interpret that certificate of clearance as though it were in fact a certificate of health. The danger, therefore, of increasing promiscuity, with all the risks of 461 venereal disease still inherent, will be increased.
I doubt very much whether the methods suggested in Regulation 33B will be found to be very practicable in working, but, even if they were found to be successful, they would deal only, and are indeed intended to deal only, with the "hard core," as the noble Viscount, Lord Dawson of Penn, spoke of it, of irresponsible, perverted and difficult people. I seem to trace something rather illogical in the speech of the noble Viscount when he dealt with that point, for, though he himself said that these provisions were directed against the hard core of vicious persons, he began his speech by showing that that was not the sole class that is under consideration, or the sole class through which the great increase in venereal disease has come. Surely the real problem of this spread of venereal disease is not that hard core, to eliminate which will obviously be a very difficult matter under any Regulations, but the large number of men—I stress "men"—and women, some of them very young, who are not in the least hardened sinners, but. who have, through one circumstance or another, drifted in these war days into a promiscuous mode of life. Consequently, I view these Regulations as a result of faulty thinking on the part of the Minister. They do not show either a true grasp of the problems involved or serious constructive remedies to meet them.
If the desire is—and of course it is—to limit the spread of these diseases and to deal with infected persons, surely the right and the first method is the increase of the number of treatment clinics. At present there are very few such clinics in country areas, and there has been a very small increase to meet the immense changes of population which have filled country areas with large masses of troops or large collections munition and other workers. The facts are, I think, these. According to the latest return there are to-day in England outside the London area—I exclude that—175 venereal disease treatment centres. There were 160 before the war began; so that only 15 new ones have been started since September, 1939. The noble Viscount, Lord Dawson, talked about the serious shortage of doctors. No doubt that is true, but is that really sufficient to justify an increase of only 15 of these clinics in these 462 three war years, with the immense needs of new areas and of large masses of people separated from their homes and from their friends? In Wales there are seven centres in one county, and there are only four centres in the other eleven counties of the Principality. That means that even if people are willing to undergo treatment, the expense involved in visiting the centres and the time involved—almost all in working hours, for there are not very many centres outside big cities that are open out of working hours—are deterrents which in fact prevent a great many patients from seeking the treatment which otherwise they would seek, and which they need and which we would wish to give them.
There is no doubt, I think, that in the pre-war years the system of voluntary treatment at available centres was to a great extent successful in meeting the needs of venereal disease incidence. Surely, then, the right and obvious thing is immensely to increase those opportunities in these war days in order to meet the new and changed needs. But I would plead for something even more than that. Is it not the fact that the Ministry of Health and the authorities of the Armed Forces have concentrated too much on merely trying to prevent or to limit the evil consequences of vicious behaviour? That policy is always largely doomed to failure. What is required surely is far more effort to restrict the vicious behaviour itself. Here is a peculiarly loathsome and crippling disease, or diseases, with terrible consequences both to the sufferers and to the children yet unborn, and they need not continue. These are diseases that could be stamped out in one generation. Why, then, not do very much more to appeal for that self-control which is in fact the only safe way of escape as in line with, and part of, the true self-sacrifice that the times in which we live and the cause in which we are engaged summon us to; in line, too, with the magnificent willingness shown by so many people, both men and women?
And when you consider the recent decision to start recruiting boys from the age of eighteen this becomes a much more urgent and pressing matter. I would assure your Lordships that many mothers have spoken to me with very grave anxiety, aghast at the thought of their boys lacking the right kind of guidance in these difficult questions as soon as they 463 join the Forces of the King. I would go even one step further. Why not have a nation-wide campaign, inspired and backed by the Ministry of Health, carried out by voluntary societies, by the Churches, by local authorities of all kinds, for instructing young people in the dangers of promiscuous relationships, and calling them to a discipline that is worthy of themselves and of the times in which they live? Is it not possible for the Minister to give deeper and wider consideration to this most urgent problem, and enlarge his vision so as to concentrate on greater measures of prevention and greatly increased facilities for voluntary treatment of the sufferers from these diseases?
My Lords, there is one point which I believe has not been brought out in this debate, although I admit I have not heard the whole of it. It always used to be an offence in the Army—I think a court-martial offence—not to report venereal disease to the regimental medical officer. I imagine that that rule still applies.
§ LORD MARLEY
My Lords, it is a fact that this sort of subject is eminently suitable for debate in the non-political atmosphere, for the afternoon, of this House. And while it is to be hoped that the Government will proceed with 33B—I am not going to discuss it this afternoon; it is a first step—it is, I think, further to be hoped that this debate will form the subject of consideration by the Government in the future activities, legislative or otherwise, which will almost certainly be needed to deal with the inevitable increase in venereal diseases. Therefore I make no apology for going a little further than the noble Lord who introduced this Motion in drawing on the experience of the United States of America. If we can learn from them something of what they are doing and something of their difficulties, we can, I think, learn how to deal with the problems with which we are going to be faced, if we are not already faced with them. Attention has been drawn to the improvement which had been effected in the venereal disease position both in Great Britain and the United States. The first million men examined by the American Army proved to have 63,000 venereal infectees. That was as regards syphilis, only one-seventh 464 as much as in 1917, and as regards gonorrhea only one-third. But those figures are based upon a routine clinical examination. I am not an expert in this matter, but the medical authorities in the United States say that the blood tests have revealed thirty-two cases of syphilitic infection for every one revealed by the ordinary examination. Could we know from the Government upon what their figures for venereal infection are founded? Are they founded upon ordinary routine and examination, or are they based upon blood tests? We should know that, so that we may at least build the foundations for the erection of a system to eliminate the disease.
We have heard a good deal about the unwillingness of infectees to proceed with the treatment provided in the hospitals. One of the reasons for that is that the treatment offered is for a very long period. Here we have something to learn from the United States. There has been developed and is in use in a great many hospitals there a five-day drip treatment. There has also been developed in Dayton, Ohio, a one-day treatment. They have got down in some places to a ten-hours' treatment. In the United States marine hospitals the treatment has been reduced to six weeks. It would be interesting to know if we are exchanging information with the American health authorities so as to secure that there is available in this country the knowledge of the progress made in the United States in the cure of this disease.
There is one other point. We have heard a good deal about the danger to the troops of infection, but nothing has been said about the danger to those other troops, the workers in the factories. America has discovered that infection comes from unstable social conditions. There are no social conditions so unstable as the bringing together of tens of thousands of people into new factory areas, and the effect of venereal infection on war production in these areas is inevitable. The Americans have discovered that prostitutes have been peculiarly active in the ship-building yards and aircraft factories. The trade unions in the United States refuse to admit prostitutes as members. In Portland, Oregon, only the other day, one trade union cleared from membership fifty prostitutes who were discovered to be following their trade in the ships which 465 were building in the shipyards there. In San Francisco they discovered women giving out cards with addresses of brothels for use in leisure hours. That is the sort of danger that may even arise to a less extent in this country, and it would be interesting to know whether the Government are giving attention to the matter. In any case it is quite clear that good home conditions, good wages, good food, good social arrangements, will militate against this danger, as will of course general education and education in prevention.
Education in prevention is of course a difficult subject, but I suggest that it is always better to put up a fence at the top of a precipice rather than provide an ambulance at the bottom. If, therefore, we can by some means prevent the infection starting, we have done a good deal. And finally, let me say that a very well-known ex-medical officer of health, Dr. Lister, now Chairman of the National Society for the Prevention of Venereal Diseases, ho s himself suggested that the prevention of knowledge has been one of the causes of the increase in venereal disease in this country. He points out that in his area in the last war, by prevention of infection, the disease disappeared, to use his own words, "as though by magic." He quotes also Sir Archdall Reid who worked, I think, in the former diocese of the most reverend Prelate—at Portsmouth—and who made a report to the same effect. In my own case, in the last war, I had a unit of 250 men, and by simple use of prophylactics available for men going on leave, with brief instructions, we reduced venereal cases to only two during the two years I commanded the unit, compared with an incidence in neighbouring units twenty or thirty times as great; and of these two cases one was due to drink and the other was that of a very young officer. I canont help thinking that if we were to provide more information in the clinics for people who may expect to incur infection, we may do something to diminish the growth of the disease, and therefore add to the war effort. I hope that the Government, in their consideration of means of dealing with this matter, will bear in mind the importance of the suggestions which have been made by many speakers in this debate.
§ LORD SNELL
My Lords, you would wish me first of all, on your behalf, to welcome the speech which was made by the right reverend Prelate the Bishop of Norwich—his first speech in his Lordships' House. We welcome it because it was cogent, penetrating, and full of serious thought, and, irrespective of whether we share the opinions of the right reverend Prelate, we all welcome his intervention. The short answer to the question on the Order Paper is that the Government policy in relation to venereal disease is effectively to control it and, if possible, to destroy it. The Ministry of Health is rightly proud of the fact that, in spite of the war, general health conditions remain good, even robust, with two exceptions—tuberculosis and venereal disease, to the latter of which Lord Winster has usefully called attention. The twentieth century, whatever its faults, may be proud of inaugurating a world campaign against both these diseases, and Great Britain has played a notable and commendable part in that war.
It is desirable that I should explain as quickly as possible the principles that guide His Majesty's Government in relation to the matter before us. Their policy is based on the principles laid down by the Royal Commission of 1913–16. These principles were: (1) Voluntary attendance for treatment, without any system of notification or compulsory powers to secure attendance; (2) treatment (both outpatient and institutional) should be available to everyone free of charge; (3) laboratory facilities for diagnosis should be available to all practitioners free of charge; (4) treatment by unqualified persons should be prohibited; and (5) education of the public should be an essential part of any arrangement of dealing with venereal disease. No. (4) of these principles—treatment by unqualified persons should be prohibited—was brought into operation by the Venereal Diseases Act, 1917. The remainder were embodied in the Public Health (Venereal Diseases) Regulations, 1916.
There were imposed upon councils of every county and county borough in England and Wales certain specific duties. They were required to provide laboratory facilities for the expert examination of specimens by doctors; they were required to start out-patients' clinics and beds for in-patients; they 467 were expected to supply doctors free of charge with arsenical preparations for the treatment of syphilis; they were asked to secure that treatment should be under conditions of secrecy, and to publish such information as would lead to the protection of the people. This policy was started by an Exchequer grant of about 75 per cent. of the expenditure, but in 1929, under the Local Government Act, this was merged into a block grant. This then is the form in which venereal disease treatment service was set up, and it has remained in force until the present time.
If we look at that policy from the point of view of success, we have to say that it did reduce the incidence of these diseases. With reference to cases of syphilis, the number that attended clinics in England and Wales in 1931 was 9,104; in 1939 the number had fallen to 4,986, or a fall of 45 per cent. The experience in Scotland was, I believe, of the same kind. Only in Sweden was there an incidence rate which was materially lower. Lord Winster drew your Lordships' attention to the fact that war always involves social disturbances, the ways of life of people are altered, and under those conditions venereal disease becomes more prevalent. That has been our unhappy experience during the present war. In regard to syphilis the newly-infected cases attending clinics rose by 47 per cent. between 1939 and 1941. The most reverend Prelate, the Archbishop of York, asked whether I could give him the figures. I am afraid I have no accurate figures, but they are estimated to be these. If the infection of the Forces is included, there has been an increase amounting to 70 per cent. The problem is increasing in gravity, but at the same time measures to meet it are also growing. Local authorities are urged to keep a careful watch over their areas, and to provide additional treatment. This concerted plan to meet increased disease is growing, and will grow stronger, we hope, very speedily.
The right reverend Prelate, the Bishop of Norwich, said that the right way to meet this problem was by an increase in the number of clinics. At the present time there are 249 such clinics in Great Britain where free and confidential treatment is 468 given. Eighteen of these clinics have been opened since the war began, five are now being prepared and will shortly be opened, and there has been started a new scheme for rural areas providing for free treatment under special practitioners—that is practitioners with a special qualification for these diseases—in their own surgeries. There are 109 of these special practitioners serving 74 areas in 11 different counties. Special attention is also being given to the Merchant Service at ports, to which Lord Winster drew attention, because these men represent a very special need. They are away from home, their ships have, as a rule, no doctors, and their case is one of urgency. The authorities are doing their best to meet it.
Regulation 33B, which represents the latest step to combat these diseases, has given rise to some controversy. There are two separate oppositions in this matter. There are those who allege that its provisions are too weak and that it is bound to be ineffective because it does not go far enough. They point to the experience of Sweden, which has had compulsory notification for the last twenty-five years and which has a lower rate of incidence, than ours. The view of the Ministry of Health is that this lower rate of incidence may not be the result of compulsion. Sweden has a population of 6,500,000—less than that of Greater London. Its population is scattered mostly over rural areas. There are only three towns with a population of more than 100,000, and, as Lord Winster has pointed out, Sweden has a very highly developed sense of communal responsibility and of health consciousness. When Lord Winster compares the state of things in Sweden with that of New York, he is not really comparing things that are comparable, because of the rural nature of Sweden and the urban nature of New York City. The Ministry of Health feels doubtful as to whether the Swedish experience would be repeated in our own country because of these differences, so 33B leaves unchanged the voluntary basis of treatment.
Then there are those who oppose compulsion in any form. They feel that it is too uncertain a method and that so far from being effective it may give a kind of false security. The argument is that women will be mainly subject to its operation and not men, that they will be deterred from undergoing early treatment 469 since they will wait for compulsion to be applied, that a false sense of security will be created amongst those who indulge in promiscuous sexual intercourse because fear of infection acts as a deterrent, that the Regulation relies on an "informer" for its operation, and that an innocent person has no redress if thoughtlessly accused by an informer. This Regulation has been most carefully framed to secure equality of treatment for both men and women. We have had it admitted in the debate this afternoon that compulsion does exist in the Dominions and in many other countries, but under Regulation 33B compulsion extends only to a group of persons small in number but responsible for much harm, who are impervious to methods of education and persuasion and who refuse to attend voluntarily.
So far as a false sense of security is concerned, that was stressed by the right reverend Prelate, the Bishop of Norwich, and also by the most reverend Prelate, the Archbishop of York, who was most anxious about this aspect of the matter. It seems to me that that anxiety rests upon a false idea as to the clearance certificate itself. A doctor will be unlikely to issue this certificate until he is medically satisfied that it is safe to the community to do so. Then the certificate is not kept by the contact but as sent at once to the medical officer of health. As to the fear that persons may give false information and that an innocent person will have no redress, the tracing of persons who spread infection does and must depend upon receiving information somehow. It is not a new practice, let it be understood, for most clinics rightly try to find out the source of infection. Every kind of precaution is taken against the dangers that have been suggested. In the first place, there are heavy penalties for false information; secondly, the special practitioners must be satisfied that the information is medically likely to be accurate; and thirdly, the medical officer of health must also be satisfied before he takes action.
The noble Lord, Lord Winster, put certain questions to me. I must ask to be forgiven if I do not answer all the arguments at length, because if I did so we should overrun the time at which we ought to close. The first question was whether treatment centres are adequate in numbers, situation, staffing and medical treatment particularly in areas to which 470 war workers have been transferred. No service is ever perfect—at least I have never been in one that was—but the Ministry of Health as well as the local authorities do keep a continuous watch on these matters and make improvements as evidence suggests that they are needed. Eighteen new centres have been provided since the war began, and as I have said five more are in course of preparation. Also for rural areas there is special provision for treatment by experienced general practitioners.
The noble Lord also asked about the need for clinics to attract women for treatment. This is a proposal which was urged some years ago by the British Social Hygiene Council and the Ministry believes it is based largely on an exaggeration of the unwillingness of women to attend existing centres. The idea seems to be that if special centres were set up dealing with gynaecological conditions generally as well as venereal diseases, and were labelled "Ailments for Women Clinics," the women would attend for treatment more readily. It is doubtful whether this argument is valid. As it is, of the 199 treatment centres in England and Wales about 75 per cent. are part of the out-patients departments of hospitals where all kinds of conditions as well as venereal diseases are treated and are not labelled as venereal disease centres. Furthermore, experience suggests that it is the adequacy of the premises and of the treatment given rather than the labels attached to them that has most influence on attendance by women.
The noble Lord asked how much is spent on research into and treatment of venereal diseases compared with similar expenditure on infectious diseases such as diphtheria, measles and so on. Our information does not enable us to state separately the amount spent on research or treatment in relation to individual diseases. We can, however, say that in 1936 the expenditure by the local authorities on venereal diseases was £450,000 compared with £3,800,000 spent on all infectious diseases. Then the question arises as to whether the arguments put forward against compulsion are really valid. I shall have to ask to be forgiven for not going into that. I have no time and I want to say something in conclusion about another aspect of the subject.
The whole question is surrounded by immense difficulties and there is a most 471 real need for a new and saner outlook in regard to it. If I, as representing His Majesty's Government, could impart into this debate my own private opinion I should be afraid to trust myself to speak about the injury which has been done by self-righteous Pharisees in regard to this matter. If these diseases are hidden it is because those who contract them are afraid to be considered as social lepers. So they hide what they ought to reveal. The psychology of both the sufferer and the community must be altered. The individual has two supreme duties in regard to his body—to keep it clean and healthy, and if it becomes diseased to get it cured as soon as possible whatever it may involve. There must be a better way of dealing with this grave problem than that of ignoring it, unless we still believe that folly and ignorance are the necessary conditions of health and virtue. The matter rests as much with the community as with the individual. These diseases thrive in the conditions of secrecy that they have had to encounter for so many years.
It is not as if these diseases were not responsive to treatment. The speech of the noble Viscount, Lord Dawson, has satisfied us on that point, and we had in this matter to a degree we have perhaps never had before the whole-hearted cooperation of the medical profession. Mr. Hilaire Belloc, in a playful and perhaps half-malicious comment, wrote these lines:Physicians of the utmost fameWere called at once, but when they cameThey answered, as they took their fees,'There is no cure for this disease.'That is not true in this matter. Medically these diseases are curable. It should be the business of the community to take every step to reduce them to the lowest possible number. It should be the duty of the individual to refrain from contracting such a disease, but if he does contract it he should get himself cured as soon as possible. I would, in conclusion, associate myself to a certain extent with what fell from the most reverend Prelate, the Archbishop of York, by saying that whatever the medical and practical aspects of the question may be there is much more than a merely physical question. Personal issues are involved, and self-control, the discipline of restraint which every man has to go through in the course of his lifetime, also has to be taken into account. These 472 qualities, which must be encouraged and developed, play an increasing part in the world war against sexual disease, which is now being waged by all civilized nations. In answer to my noble friend Lord Marley, I will say that this debate will be carefully noted by the Department concerned, for which I am speaking to-day. I thank the noble Lord, Lord Winster, for the useful and timely discussion which his Motion has evoked.
§ LORD WINSTER
My Lords, I think your Lordships will agree that a Motion which has drawn such speeches as those to which we have listened to-day from the most reverend Prelate, from the noble Viscount, Lord Dawson of Penn, and from the right reverend Prelate is well justified. I would say to the most reverend Prelate, to whose opinions I always listen with deep respect, that nothing I have said was intended to contradict the teaching of the Church on this subject, to condone sin or to minimize the importance of continence and self-control in these matters. I noted what the most reverend Prelate said on the subject of silence, and that he said that these matters are discussed widely among young people. I fear that much of that discussion is furtive, and I wish to see it encouraged and brought out into the open by a more frank attitude on the part of the Government and public men to these matters. I think it was the most reverend Prelate who, in referring to Regulation 33B, spoke of anonymous informers. In my view, it is most important to have that matter made straight, because I understand that information, in this connexion, must come from individuals who are under treatment for venereal disease and, therefore, there can be no question whatever of any anonymity about the matter. The hour is late, and I will not refer to other points which have been raised in the course of the debate. I would, however, like to thank the noble Lord, Lord Snell, for so kindly replying to the questions I ventured to put to him. As he has assured us that the policy of the Government is a policy which aims at control and elimination of the evil, I feel that it is a most satisfactory and adequate reply. I therefore beg leave of your Lordships to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.