Prevention vs. Punishment

Originally published June 26, 2017, by Planned Parenthood Advocates of Arizona.

Before antibiotics, syphilis could kill and gonorrhea was responsible for most cases of infertility. Both diseases could spread from husband to wife to baby, potentially destroying families. So you’d think medical breakthroughs in prevention and cures would be welcomed with open arms.

The actual history, like the humans who create it, is much more complicated.

Compassion, rather than fear and guilt, should guide medical practice.

During World War I, sexually transmitted diseases were a huge problem — second only to the 1918 flu pandemic in the number of sick days they caused (7 million, if you’re counting). The Roaring Twenties saw a sexual revolution, and by World War II, the military was once more fretting about losing manpower to debilitating infections that drew men away from the front lines and into the sick bays.

The armed forces did what it could to suppress prostitution and distract soldiers with recreational activities. But the human sex drive could not be contained: The vast majority of U.S. soldiers were having sex — even an estimated half of married soldiers were not faithful to their wives during WWII. Victory depended on soldiers’ health, so during both WWI and WWII, the military provided its sexually active soldiers with “prophylaxis,” medical treatments that could reduce risk for venereal disease — or VD, as sexually transmitted diseases were called back then.

Anyone who thinks condoms are a hassle or “don’t feel good” should read medical historian Allan M. Brandt’s description of a WWI-era prophylactic station, which soldiers were instructed to visit after sexual contact:

A soldier reporting for the treatment would first urinate. Then, on a specially constructed stool, he would wash his genitals with soap and water followed by bichloride of mercury, while the attendant inspected. The attendant would then inject a solution of protargol [silver proteinate] into the penis, which the soldier would hold in the urethra for five minutes, then expel. After the injection, calomel [mercurous chloride] ointment would be rubbed on the penis, which would then be wrapped in waxed paper. For the prevention to be effective the soldier could not urinate for four or five hours following the treatment.

The high demand for prophylaxis and the logistics of running these stations led to the development of “pro-kits” — prophylaxis that could be self-administered using a mercury-based ointment, carbolic acid, and camphor. During WWII, condoms were also made widely available — in fact, the military couldn’t keep up with demand.

Looking after soldiers’ health shouldn’t be controversial — but it was. Even with our troops’ lives on the line, critics argued that VD should be controlled by promoting morals — and that encouraging any means of prevention other than celibacy was an endorsement for promiscuity. The American Social Hygiene Association claimed prophylaxis, by encouraging promiscuity, would actually lead to more venereal disease, not less. Secretary of the Navy Josephus Daniels thought prophylaxis would “destroy the very foundations of our moral and Christian beliefs.” Others worried that prophylaxis would allow individuals to evade responsibility for their actions — escaping the punishment they deserved.

Late in World War II, a medical breakthrough came in the form of penicillin. Now gonorrhea and syphilis could be wiped away within hours, using a drug with very few side effects. It sounds like glorious news, but not everyone saw it that way. Dr. John Stokes, the country’s leading “syphilographer” (there’s a job you don’t hear about anymore), worried that the elimination of VD “would have heavy costs in the social, moral, and material life of man. A world of accepted, universalized, safeguarded promiscuity is something to look at searchingly before it is accepted.” Criticisms like these echoed the fears expressed earlier in the century, when Salvarsan was introduced as the first effective treatment for syphilis. Dr. Howard Kelly, for example, said, “I believe that if we could in an instant eradicate the diseases, we would … fall wholly under the domination of the animal passions, becoming grossly and universally immoral.”

It seems absolutely incredible that a quick, easy cure for two devastating diseases — syphilis and gonorrhea — would be decried as the tip of a slippery slope leading to widespread depravity. But critics worried that, with the fear of consequences taken away, “sexual morality” could no longer be promoted as the best way to protect the family, and the family unit would be weakened as a result. They really did seem to see a silver lining in disease — as a tool to control other people’s behavior and sexuality.

If you could go back in time, what would you say to these people?

It turns out you don’t actually need a time machine to find people who believe preventing STDs does more harm than good. Just look at the HPV vaccine, which caused a stir among more conservative members of society when it was introduced in 2006. They expressed fears that vaccination against HPV was tantamount to “permission” to have sex. It’s chilling that, for some people, women’s “sexual purity” is worth more than their lives — worldwide, cervical cancer kills 270,000 people each year. (Studies have shown vaccination makes no difference in terms of number of sexual partners or age of sexual debut.)

Another source of controversy is PrEP, or “pre-exposure prophylaxis,” a pill that protects users from acquiring HIV. PrEP on its own is about as effective as condoms — and, when combined with condoms, reduces HIV risk even more dramatically, providing 92 percent protection against HIV over the course of a year. Some, however, worry that, with the fear of AIDS off the table, PrEP will give users license to be “irresponsible.” (These fears have not been supported by surveys or clinical trials.)

The belief that disease is fair punishment for improper behavior, and that prevention allows us to avoid consequences of our actions, is as old as the hills. It can be expressed in religious terms (AIDS as God’s wrath) or in secular terms (people with lung cancer brought it upon themselves by smoking). You can even see it in Congress, such as when Rep. Mo Brooks argued that people without preexisting conditions “lead good lives” and have “done things the right way,” implying the flip side, which is that people with preexisting conditions have not.

Is fear of cancer, AIDS, and other diseases a tool for controlling other people’s behavior, enforcing a single idea of morality? And if so, is the power to control others through this fear more important than alleviating the suffering cancer, AIDS, and other diseases cause? Is a tool of behavioral control really more valuable to us than tools to alleviate people’s suffering through preventing or curing disease?

It is important that people receive accurate information so they can make their own decisions about risk — after that, people need to be trusted to manage their health in the ways they see fit. When we separate people into the “guilty” and the “innocent,” we stigmatize sick people and add to their suffering. When we blame them for their own poor health, we lose sight of the compassion we should have for one another. And when we don’t help the “other” be healthy, we all lose, since a healthy society is made up of healthy individuals. The values of nonjudgment and compassion should guide medical practice — not the desire to control people.

Abstinence is a fantastic option for avoiding STDs, but it’s not one size fits all — it needs to be one option among many. Back in the days before condoms, vaccines, and medications, the only option we had was abstinence, but let’s be realistic: Throughout history, people have been having sex with multiple partners, spouses haven’t always been faithful to one another, and — tragically — sex can be forced or coerced. The more our options expand, the more flexibility we have to find prevention strategies that will work for our own unique situations. Expecting “morality” to be our only path to good health and suppressing other effective methods of prevention is, in fact, what is immoral.