March 30, 2008

STD Rates Should Embarrass The USA

Sexually transmitted diseases (STDs) are incredibly common here in the US. The frequency of infection was highlighted earlier this month with a study released by the Center for Diseases Control (CDC). In that study estimates that
"one in four (26%) young women between the ages of 14 and 19 in the United Sattes-or 3.2 million teenage girls-is infected with at least one of the most common sexually transmitted diseases (human papillomavirus (HPV), chlamydia, herpes simplex virus, and trichonomiasis)."

That is an incredibly high infection rate for a country like ours, we occupy a rather unique position in that few countries have the resources we do to prevent and treat STDs. And honestly there are very few countries who squander such resources so effectively.

Considering the breadth and systemic nature of the problem it makes sense to examine our public policy measures to evaluate just how effective our current plan is at battling the spread of STDs. An effective, sane, national STD-prevention policy will be built on the three pillars of education, vaccination, and testing.

Doctors on the front lines of STD prevention say that they have little hope of effectively stopping the spread of common diseases. One problem is that most visits to clinics about STDs only involve one partner and only in 11 states is it legal to treat the absent partner. Another problem that doctors face in the clinics is that patients will show up to get a short treatment and disappear until their next bout of discharge.

So knowing this information it would make sense that people be educated on infection and disease progression. A large majority of the public doesn't understand the course of disease treatment or transmission risks. Calls for greater public awareness have been called for many times in the past and the Institute of Medicine issued a report on the state of public awareness and STD transmission in 1997. The article cites the need for stronger leadership within the public health policy makers.

We sit 11 years later in a very similar situation and the rates of STD infection continue to rise. In the early 1990's after the HIV/AIDS scare began the rates of all infection dropped, but soon after began to rise again as public awareness of HIV/AIDS died after the initial sensationalism began to fade away.

Knowing that public awareness drops the rate of infection it would seem that the government would be pushing very hard for comprehensive education concerning STDs and sexual health. But in fact the opposite is what has happened over the last 10 years. The idiocy that is "abstinence only programs", a politically popular but scientifically discredited idea negatively affects the public policy. So mark a fail down on the public education pillar. Abstinence-only does not remove the stigma from STDs and sexual health. If anything it creates a taboo around sex which closes the channels of communication between adults with answers and children with uncertainty. This is unacceptable and a comprehensive education program needs to be put into place.

Vaccination has recently become available for one of the most widely spread STDs; HPV. Gardasil was approved last year for prevention of certain cancer-causing strains of HPV. Besides vaccinating against the HPV virus this is the first widely available vaccine aimed directly at preventing cancer (The Hepatitis B vaccine also helps prevent liver tumors). Gardasil can prevent cervical cancer, certain mouth and anal cancers, and maybe other cancers of the naughty bits.

Unfortunately this vaccine has been met with quite a bit of resistance from the religious right. Since the infection that leads to these cancers is usually spread by sexual contact the fundies consider it a big no-no. Some religious groups (Christianity today) favor an "opt-in" policy, while others such as Focus on the Family want a "let the parents decide" policy. The obvious imbalance with those policies are that the parents are not the ones deciding to, or not to, have sex. "The wages of sin is death", and while most Christians don't subscribe to a literal interpretation of the idea, it does infuse the Right's decision-making, perhaps blinding them to the benefits of the vaccine. Nobody likes to think of our kids having sex at 14, it may happen, and to punish them with cancer is excessive.

An "opt-in" policy is not effective to public health. Vaccines work by protecting people before they may be exposed, and by creating herd immunity. Opt-in carries implications that the vaccine is unimportant or of uncertain utility. Opt-out, while less negative, makes it too easy for people to put off a decision until it is too late.

With nationwide vaccination the idea is that the greater good to a greater number of people despite the potential damage to a small number of people. There is little doubt of the value of vaccines and I think it would take a very good spinster to argue that vaccines for polio, smallpox, measles, mumps, the flu, and other illnesses have not benefited society. Millions have lived as a result ,escaping what was many times a certain death. I think if Gardasil prevented ovarian or breast cancer there would be a lot less resistance to its implementation.

To be fair many places, including my home state of Texas, have implemented mandatory vaccination with Gardasil. This should be a good study in caner rates and HPV infection between states in the next 10 years.

The third pillar of STD prevention is mandatory screening. It is very hard to prevent transmission of a disease if you don't even know you have it. Unfortunately that is the story with most teens and young adults. Screening and early testing is the best way of managing already infected populations as well as preventing the spread of diseases. Knowledge only increases the power of prevention and with today's very effective tests there is no reason that we shouldn't require people to at least go find out if they are a carrier to a potential spreadable disease.

Our public policy needs to more accurately reflect the reality of the situation. Education, vaccination, and testing need to become ingrained in our public policy and passed down to future generations. People will always have sex. Always. And as long as they do, there will be STDs. But to live in a rich, technologically advanced nation, and have STD rates as high as we do is not only embarrassing, its a travesty.

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