Treatment for Venereal Disease: The Public Health Clinics

In Baltimore, in the 1920s, a great social silence surrounded the problem of syphilis. The negative social stigma associated with venereal diseases caused extensive underreporting. Physicians endeavored to save patients and their families from possible embarrassment by attributing syphilis deaths to other causes. A tacit social conspiracy of silence resulted: Patients did not talk about their diseases, physicians did not report them, the health department did not publicize them, and the newspapers never mentioned them. The diseases were thus largely invisible. Many hospitals and physicians refused to treat patients with venereal diseases; physicians who specialized in these diseases could make a great deal of money from private patients.^[7] Many patients, however, could not afford private medical care.

In the aftermath of World War I, the city health department began quietly to treat venereal diseases in its public clinics. The first such clinic, which opened in 1922, had thirteen thousand patient visits in its first year of operation. The clinic population grew so fast that the city soon opened a second clinic, and then a third. These patients, brought to the public clinics through poverty, were recorded in health depart-

ment files as venereal disease cases. Like all the diseases of the poor, they attracted little public attention. Syphilis among the wealthy was covered with the silence of discretion; syphilis among the poor was covered with a silence of public disinterest.

The venereal disease problem in Baltimore was, however, turned into news by a survey conducted by the U.S. Public Health Service in 1931.^[8] The Public Health Service described syphilis as a major problem in Baltimore, and defined it as a problem of the black population. The "colored" rate was especially high at 22/1000 for males and 10/1000 for females; this contrasted with a reported white rate of 4/1000 for males and 1.3/1000 for females. Of course, whites were more likely to be seeing private physicians and were therefore less likely to have their disease reported to the health department. Syphilis, which had originally been perceived as a disease of vice and prostitution, was thus redefined as a black disease.

The treatment of syphilis might well have been considered a punishment for sin. The recommended treatment required sixty or more weekly clinic visits, with painful injections in alternating courses of arsenicals and heavy metals. The minimum effective treatment required forty weekly visits. To the distress of health officials, many patients drifted away from the clinics as soon as their symptoms had been relieved; only half the white patients and a third of the black patients stayed to receive the minimum necessary treatment.^[9] Fewer black patients continued in treatment because many of the white physicians and nurses were said to have an unsympathetic attitude to black patients. In 1932 the health department employed black physicians and nurses, hoping to increase the rate of successful treatments:

Indeed, after several years of experience along these lines, it can safely be concluded that the best results are obtained by encouraging the colored race to take care of its own people. . . . The success of these clinics is unquestionably due to the fact that colored physicians have a more sympathetic approach and a better understanding of the psychology of the Negro race.^[10]

As the depression deepened, patients who previously would have been able to pay were increasingly forced to depend on the free public clinics. In 1932 the public clinics were becoming more crowded than ever before, now with more than 84,000 annual visits. The city health department, already burdened with tight budgets and increasing health problems of every kind, complained that the hospitals in town were dumping poor patients on the city clinics.^[11] The city health department wanted to

distribute the then current chemotherapy—neoarsphenamine, sulpharsphenamine, and salvarsan—free of charge to physicians and hospitals for the treatment of indigent patients; but with cuts in their own budgets, they could do little beyond helplessly watching while the clinic population continued to grow.

In 1933 the problem of overcrowding became so acute that the city health department was faced with a real crisis. The department decided to concentrate on patients at the infectious stage of syphilis. They discontinued treatment to any patients who had already received four courses of arsphenamine—that is, patients who had received sufficient drugs to render them noninfectious to others, even though they had not themselves been cured.^[12] The reason for the change in policy was reduced health department funding; its justification, that health departments should primarily be concerned with rates of infection, and not with individual cures.

The new operating rules instituted in 1933 effectively changed the character of the health department clinics. Previously, the clinics had been operated as treatment facilities for patients who could not afford the fees of private physicians; however crowded, however inadequate the medical attention, they had at least intended to cure their patients. Now the clinics no longer pretended to cure but simply to render people noninfectious. For the poor, it became impossible to receive full treatment. The unemployed could not afford the expensive series of weekly treatments given by private physicians, but they could not get jobs if they tested positively for infection.