The Hidden Epidemic: Confronting Sexually Transmitted
Diseases
BMJ 1997;315:1477 (29 November)
Institute of Medicine:
National Academy Press, £32.95, pp 275
ISBN 0 309 05495 8
There is a tendency to look on AIDS and
HIV and other sexually transmitted diseases as issues largely
of the developing world, particularly sub-Saharan Africa and
Southern and South East Asia. However, some rich
industrialised countries, particularly the United States, have
an epidemic of sexually transmitted diseases (about 12 million
new cases annually, of which 3 million occur in teenagers),
and no national coordinated control programme of education and
clinical services.
The Hidden Epidemic is the report of a 16
member committee on prevention and control of sexually
transmitted diseases set up by the Institute of Medicine to
assess the current impact of such diseases and to
"provide direction for future public health programmes,
policy and research in STD prevention and control."
The committee is clear that a national
system for preventing sexually transmitted diseases needs to
be established and that it makes economic sense to do so. The
report estimates that only $1 is invested in preventing
sexually transmitted diseases for every $34 spent on managing
such diseases (direct and indirect costs), and it calls for a
system based on a national coordinated policy, made up of
local, state, and national programmes. The report recognises
that to do this will require policymakers (in both public and
private sectors) to show strong leadership built through
alliances and will need to overcome barriers to adopting
healthy sexual behaviour, with particular emphasis on
adolescents and other populations who often fail to access
services.
The report stresses the need to prevent
sexually transmitted diseases, and that this means that
interventions should focus on adolescents before sexual
activity is started. It states that all school districts in
the United States should see that schools provide appropriate
services, including health education, access to condoms, and
readily available clinical services, which could be school
based.
The report finally addresses the issue of
how to ensure access to and quality of essential clinical
services for sexually transmitted diseases. Unlike in Britain,
no network of clinic based specialist service exists. The
report does not recommend this particular system and,
interestingly, calls for a mixed model of integrated and
specialist services which is more akin to that used in the
developing world. The committee members therefore recommend
that comprehensive services for sexually transmitted diseases
should be incorporated into primary care and reproductive
health services. To complement this, they call for improvement
in dedicated public clinics for sexually transmitted diseases.
Finally, the issue of who pays is crucial
to any control programme. Ideally, when dealing with a major
public health problem with associated stigma, it is best that
services are open access and free. In the United States this
is largely not so, and the report examines ways in which
health plans and managed care organisations could tackle this
financial issue, but it does not go so far as to suggest that
all services should be free and centrally funded.
The book is intended for a wide audience
involved directly or indirectly in preventing sexually
transmitted diseases or who have an interest in general public
health policy. This is an excellent book that lays down the
foundations, backed by evidence, of what needs to be done
rather than how this can be achieved. It will provide an
essential text for those wishing to act as advocates for the
setting up of control programmes in the United States. Since
much of the background information contained in the book
relates to North America, it is probably not of a wider use
for programme managers. However, for those interested in the
public health issues related to sexually transmitted diseases,
it does provide good background information on the epidemic
and economic social issues in the United States.
Michael Adler, professor of genitourinary
medicine/sexually transmitted diseases, University College
London Medical
School, London
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