Chapter 6

SECTION 1.--STATISTICAL.

(A.) _Medical Statistics._

The first item on the Committee's order of reference is "To inquire and report, as to prevalence of venereal diseases in New Zealand."

One of the first matters which engaged the attention of the Committee was the question how reliable information could be gathered which would indicate the present prevalence of these diseases in this country. Recognizing that it would be impossible to obtain trustworthy figures without securing the widespread co-operation of the medical profession, the Committee at an early stage sought and was readily given the help of the British Medical Association in the matter. Representatives of the Association gave their assistance in the preparation of a form to be sent to and filled in by all practising members of the profession, and in the current number of the _New Zealand Medical Journal_ an appeal to members for their collaboration was made. Suitable circular letters were also prepared by the Committee asking medical practitioners for their co-operation, and the Committee are pleased to be able to report that out of about 750 in actual practice, no fewer than 635 medical practitioners sent in completed returns. A copy of the form used for these returns will be found as an appendix to this report, as also a tabulated return of the replies received and compilations therefrom.

It will be seen that the total number of cases of all forms of venereal diseases and of diseases attributable to venereal disease under the personal care of the doctors reporting is 3,031; and, taking the population of New Zealand as 1,296,986 (estimated population 31st March, 1922), this means that about one person in every 428 of our population is at present being treated for venereal infection or for the results thereof. Acute and chronic gonorrhœal infections give a total of 1,598, being about one person in every 812 of the population. This is most likely a very low estimate, for the Committee have had it very definitely in evidence that many persons suffering, at least from acute gonorrhœa, seek treatment at the hands of persons other than registered medical practitioners. For syphilitic infections in all forms the total is 1,419, about one person in every 914 of the population. The return bears out other evidence showing that the chancroid or soft-sore type of infection is rare in this Dominion.

The Committee regard the result obtained as furnishing some indication of the amount of active venereal disease existing in the Dominion. The Committee consider, however, that these figures must be considerably on the low side, for these reasons: (_a_) that a number of medical practitioners have not replied: (_b_) that some diseases attributable to venereal disease may not have been conclusively diagnosed as such, and, therefore, not included in the return. The return necessarily does not include cases, probably numerous, which have not been under medical care for some time, if at all; (_c_) to secure a complete return would have involved the keeping by each doctor of full records of all cases and a careful and laborious collation of figures.

With respect to the expression of opinion asked of medical practitioners upon the question "If venereal disease in this Dominion has or has not increased in a greater proportion than the population during the last five years," it will be seen that of 322 who replied, 199 answered "Yes" and 203 "No." This is necessarily purely a matter of impression, and it must also be borne in mind that the evidence shows that patients are now using the clinics in large numbers, while others who formerly went to general practitioners now consult specialists who have recently started in practice. On the other hand, it is possible there is a compensating influence in the fact that the public are being educated to the importance of seeking skilled medical treatment for these diseases.

(B.) _Clinic Statistics._

A second source of information as to the prevalence of venereal diseases was provided by the statistics which have been compiled by the Department of Health as the result of the establishment of the venereal-diseases clinics. Among the appendices to this report will be found a return showing the number of persons attending at each of these clinics for the years 1920, 1921, and part of 1922, and recorded under the headings "Sexes" and "Diseases." These statistics are valuable insomuch as they record facts, but with respect to the total prevalence they are but an indication, since they relate only to a small proportion of the population who have become infected and sought treatment. From this table (B) it will be found that the males attending for the first time represent 83.60 per cent. of the total, and females 16.40 per cent., or, roughly, a ratio of six males to every female.

_Clinic Distribution._--In the figures for syphilis the following points are worthy of note: Auckland: A distinctly higher number of cases than the other centres. A marked drop in 1921 for males, but the return for this year indicates a rise; female cases show a rise for this year. Wellington: Returns appear fairly uniform, with a slight falling tendency, most marked in the females. Christchurch: A drop in male cases, with a fairly uniform rate of females. Dunedin: Here the rates appear uniform, with exception of a fall for males in 1922.

As to gonorrhœa, these points may be noted: Auckland: A marked rise. Wellington: Steady rise with exception of females. Christchurch: Slight rise since 1920: females uniform rate. Dunedin: Slight rise, with indication of male increase in 1922.

_Age Distribution._--The age-period of persons attending the clinics is mainly eighteen to thirty.

_Marital Condition._--From the evidence of the clinics it is very apparent that venereal disease is especially a problem associated with the unmarried.

(C.) _Mental Hospital Statistics._

A third source of estimation of prevalence was opened to the Committee by the Inspector-General of Mental Hospitals. The method of investigation adopted by Dr. Hay is based on Fournier's estimate that 3 per cent. of the cases of syphilis existing at any one time will ultimately develop dementia paralytica.

The introduction of the Wassermann test and treatment by salvarsan or other arsenical preparations will vitiate this index in future, for the reasons that by the Wassermann test more cases will be diagnosed, and by the use of recent remedies the complete cure of many more cases will be effected, and consequently fewer will develop dementia paralytica. This disability does not develop until about ten to fifteen years after infection. The Wassermann test and the modern arsenical preparations have not yet been in use for that period, therefore these figures, as an estimate of the prevalence of syphilis in 1921, would not be materially affected by these developments. An estimate based on these data may therefore be regarded in the meantime as approximately correct.

During the past ten years 4,763 males and 3,747 females have been admitted into New Zealand mental hospitals. The percentage of syphilitic admissions of all types was 4.74, while the percentage of cases of dementia paralytica was 3.89. In other words, of the admission of syphilitics 82 out of every 100 cases were dementia paralytica. The average yearly number of deaths from dementia paralytica according to the Government Statistician's returns between 1908 and 1921 was just under 40.

If Fournier's estimate that 3 per cent. of syphilitics ultimately develop dementia paralytica be accepted, one would arrive at the annual infection by multiplying 40 by 33, which gives 1,320. Assuming the average duration of life, after infection, to be twenty-five years, this means that at any given time there are twenty-five years' infections on hand. Dr. Hay computed from this the number of persons in New Zealand now who have, or have had, syphilis to be 1,320 x 25, equalling 33,000, or 1 to every 38 of the population. If the average duration of life after infection were assumed to be thirty years, the figures would be 1 to every 32 of the population.

Taking the figure for syphilitic infections over a period of years at 1,320 per annum, this would mean for the population of New Zealand (exclusive of Maoris) 1 fresh infection annually in about every 850 persons.

(D.) _Incidence among Maoris._

It is even more difficult than in the case of the European population to say what is the prevalence of venereal diseases amongst Maoris. The Director of the Division of Maori Hygiene (Dr. Te Rangi Hiroa) in a statement to the Committee says:--

"Venereal disease made great ravages amongst the Maori population in the early days of colonization. To this may be attributed much of the sterility, with histories of repeated miscarriages, that existed in the transitional period of Maori history. Most of the old men--hemiplegias, and paraplegias, and subsequent general paralysis of the insane--gave an old history of syphilis. These cases that I saw twenty years ago have now disappeared.

"In my experience of eighteen years' constant work amongst the Maoris venereal disease has been comparatively rare. It disappeared amongst the people, only to recrudesce in some localities as fresh infection was introduced by the white man, or brought back to the settlements by visits to the white towns. I see very little of it at present, but now and again hear reports from medical officers that it has cropped up in the settlements near them ... In all these cases I am convinced that the origin is from a white source, and the problem amongst the Maoris is not nearly so serious as amongst Europeans. It seems to me unjust that the idea should be circulated that the Maoris are a source of danger to the European community--the reverse is much more likely.

"It is impossible for me to supply accurate data as to the incidence of the disease amongst the Maori race at present, but I am confident that reports have a natural tendency to become exaggerated. I do not consider that returned Maori soldiers, owing to the treatment they received before being discharged from the service, have been a factor in the introduction of the disease amongst the settlements. If they have in some areas, it has been from fresh infection, which their experience of prostitution in Egypt and Europe has made them more liable to acquire from professional and amateur prostitutes in towns. At the same time, the experience of returned soldiers as to the value of treatment makes them more likely to seek such aid."

(E.) _Death-certificates._

There are no trustworthy statistics in any part of the British Empire of the deaths due to venereal disease. Many persons die from illnesses which result from an initial syphilis contracted perhaps many years prior to death. It is well known that medical practitioners, from a laudable desire to spare the feelings of relatives, refrain from stating the primary cause of death in such cases, and merely enter the secondary or proximate cause. For the same reason, the statistics regarding deaths due to alcoholism, and perhaps in a less degree some other factors in the mortality returns, are incomplete and consequently useless.

Both the Royal Commission on Venereal Diseases and the Birth-rate Commission recommended that the medical attendant should issue two certificates--one, which would be a simple certificate of death, to be handed to the relatives, and the other, a confidential certificate giving the primary cause of death, which would be transmitted to the Registrar.

The Registrar-General for New Zealand, Mr. W.W. Cook, in his evidence in chief, stated that he did not favour these suggestions. A certificate of death, he said, cannot be regarded as confidential, as the information contained therein is recorded in the death entry, which may be inspected by the public, and of which a copy may be obtained by any applicant. In reply to questions, however, he stated that the law could no doubt be altered so as to make the death-certificate confidential, the information to be given up only on an order from a Court of justice. Apart from the fact that the insurance companies might object, he did not see any objection from the public point of view.

Mr. Malcolm Fraser, the Government Statistician, said that there was considerable division of opinion on this question at the British Empire Statistical Conference held in London in 1920, when statisticians from all parts of the Empire were present. It was generally agreed that the system was good theoretically, but some doubt was expressed whether in practice there would be as much improvement as was expected, since the system would depend entirely on the medical attendant strictly complying therewith and disclosing the true cause of death in every case. Any system of confidential information always had that failing. The witness thought the register must be open for persons having a right to call for copies of entries. In dealing with insurance claims at death the truth or otherwise of the statement in the proposal form was important, and might require verification by inspection of the death entry. At the Conference Dr. Stevenson, the Statistician to the Registrar-General of the United Kingdom, was very pronounced in his advocacy of the confidential form of certificate. The Conference passed the following resolutions: "(1.) That the present system of open certification tends to prevent candid statements of the causes of death, and thus introduces a systematic error into death statistics. (2.) That the error would be eliminated by a system of confidential certification."

The Committee, while agreeing that such a system of registration of deaths would undoubtedly afford better means of approximating to correct returns of mortality not only from venereal diseases but also from alcoholism and some other diseases, would point out that, if New Zealand were to adopt the reform while the rest of the Empire retained the present system, the result would be to place the Dominion in an apparently unfavourable light in comparison with other parts of the Empire in regard to the mortality from these diseases.

SECTION 2.--CAUSES OF THE PREVALENCE OF VENEREAL DISEASES IN NEW ZEALAND.

In discussing this order of reference the Committee desire it clearly understood that these causes are not peculiar to New Zealand, and do not operate more extensively in New Zealand than elsewhere. The Committee are concerned, however, in discussing this question only as it affects New Zealand.

The causes of the spread of venereal disease may be classified under two main headings: (1) The presence of infected individuals acting as foci of infection; (2) the occurrence of promiscuous sexual intercourse, by which in the great majority of cases the disease is actually transmitted from one individual to another.

(1.) _The Presence of Infected Individuals._

These sources of infection arise and persist for the following reasons:--

(1.) Neglect by infected persons to undergo treatment. (2.) Neglect to continue treatment till no longer infective. (3.) The treatment of infected individuals by unqualified persons, such as chemists, herbalists, chiropractors, &c. In these cases the disease becomes chronic, and the best opportunity for its treatment and cure has passed before the case is seen by a medical man. (4.) By the introduction of venereal disease to this country from overseas.

(2.) _The Occurrence of Promiscuous Sexual Intercourse._

A striking portion of the evidence placed before the Committee was that which showed the very small amount of professional prostitution in New Zealand. This was supported by the valuable evidence of Mr. W. Dinnie, ex-Commissioner of Police, and Mr. A.H. Wright, Commissioner of Police. The latter witness stated that there were only 104 professional prostitutes in the Dominion.

It would appear also that the professional prostitute, as a result of her knowledge and experience, is less likely to transmit venereal disease than the "amateur." It is therefore principally to clandestine or amateur prostitution that one must look for the dissemination of the disease, and inquiry into the conditions which tend to the production of the amateur prostitute is a direct inquiry into the causes of the prevalence of venereal disease.

The evidence before the Committee shows that this promiscuity is very prevalent, and that it is not confined to any particular social strata. The fact is also strikingly demonstrated by Table A in the appendix. From this table it will be seen that during the period 1913-21 there were 10,841 illegitimate births and 33,738 legitimate first births within one year after marriage. If to the illegitimate births we add the total number of live births occurring within the first seven months of marriage viz., 12,235--which may be safely considered to have been conceived before marriage, we get a total of 23,076 births in which conception took place extra-maritally. In other words, more than 50 per cent. of total first births occurring within twelve months of marriage result from sexual contact prior to marriage.

Some factors which contribute in a greater or less degree to the moral laxity which leads to promiscuous sexual intercourse are:--

(1.) The relaxation of parental control, which was emphasized by many witnesses. Girls stay less at home and assist less in the work of the home, preferring whenever opportunity offers, to go to the pictures or some other form of entertainment.

(2.) Lack of education of the young in the facts pertaining to sex. Especially the Committee would call attention to the unfounded belief of many that continence in young men is injurious to health.

(3.) Bad housing and general conditions of living. When members of both sexes are crowded together in restricted accommodation in which often insufficient conveniences are supplied, it is easy to conceive of a relaxation of the proprieties of life which might lead to acts of immorality.

In this connection the Committee desire to call attention to the excellent work done by the Y.W.C.A. and other bodies in the provision of hostels in which girls are provided with board and lodging at very reasonable cost. The Committee were surprised to learn that full advantage was not taken of these provisions, and that the accommodation at these hostels was not fully occupied. It would appear that many girls resent the very slight amount of supervision and restraint exercised over them, precisely as they do parental control.

(4.) The presence in the community of individuals, especially girls, who are to some degree mentally defective or morally imbecile. The Committee were given several individual instances in which such girls had acted as foci of infection; they are easily approached, and facile victims for men. In spite of a degree of mental or moral defect they may be physically attractive.

(5.) Economic conditions which delay marriage may reasonably be regarded as a factor in conducing to an increased frequency of extra-marital sexual relationship. Graph A in the appendix shows clearly that the age of marriage in both sexes has, with slight fluctuations, steadily increased from 1900 to 1921.

(6.) Alcohol tends to the dissemination and persistence of venereal disease: it increases sexual desire, lessens control, causes the individual to be less careful as regards cleanliness, &c., after exposure to infection, and militates against effective treatment. It is to be pointed out, however, that the lower control possessed by some individuals may be the actual predisposing cause, both of laxity in sexual matters and of the excessive ingestion of alcohol. There appears no doubt that alcohol is an important factor in the prevalence of venereal disease, although probably not so potent as represented by some witnesses.

(7.) Accidental infections are undoubtedly rare. They may arise from contact with W.C. seats, dirty towels, and eating and drinking utensils in public places.

(8.) Other factors of minor importance which were mentioned in evidence were the modern dress of women, which was stated to be in certain cases sexually suggestive, and certain modern forms of dancing. There appears some grounds to suppose that dances conducted under undesirable conditions contribute to sexual immorality, but the Committee see no reason to condemn dancing generally because the coincident conditions under which it has been or is conducted in some cases have contributed to impropriety. The cinema was stated by some witnesses to have an immoral tendency both in the nature of the pictures presented and in the conditions under which they are viewed by the audience. The Committee suggest that a stricter censorship might with advantage be exercised, and should include the posters advertising the films.

It has been stated that venereal disease has increased in New Zealand with the return of the Expeditionary Force from overseas. Ample evidence, however, was given to the Committee that there has been no increase of the disease due to returned soldiers. These men were treated prior to their discharge until non-infective.