468
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
NOVEMBER, 1975
Gonorrhea's Trojan Horse: The Asymptomatic Female Carrier EDWARD L. C. BROOMES, M.D., Lakeside Medical Clinic, East Chic-ago, Indiana
Gonorrhea is a curable disease. Effective treatments that are almost specific are available. The results are usually predictable. Yet, paradoxically, in terms of a public health and epidemiological problem it has defied every effort for control.'1-1 Its rising incidence, attested by available statistics,1 makes self evident this failure. The fact that very few physicians in their private practice report their "social disease" cases, contributes largely to this frustration and reduces every officially published statistic to the status of an educated guess.2 For reasons that should be obvious, most cases of venereal disease are seen in private practice and these by physicians who are in general practice.3 These physicians, then form the front line, both in the attack and defense in any anti-venereal campaign. Because of a still existing social stigma and the readily understood threat to marital harmony, not many individuals, even when indigent, seek treatment in public clinics because their identities may be exposed. In the ambience of confidentiality associated with the office of the private practitioner, is to be found the key to any successful anti-venereal program. Physicians who do not participate directly in the community program, can still make a striking and effective contribution. However, this requires that they maintain a high index of awareness 4'8 as to the female carrier. This must be expressed as a serious concern, and demonstrated by a pragmatic but tactful cynicism in investigating the suspected contact, who must first be identified and then induced or persuaded to be examined and treated. To the tactful and considerate physician, this would seldom present a difficulty. The opinions expressed in this paper are
the products of an observation that extends over 30 years of general practice in a largely ghetto area, in one of the most industrialized cities in the Midwest. The clientele embraced an ethnic spectrum of whites, blacks, and Latins. Gonorrhea and its complications have been and still remain a very frequently treated disease in the practice. As a consequence of these credentials, the writer feels entitled to express opinions even when they contradict popularly held and taught concepts. Early in his experience the physician is struck by a singular observation. Seldom did the female, "fingered" by his patient as the "contact", display any of the symptoms or stigmata of the disease. He is further perplexed when a negative pelvic examination of the contact is supported by a laboratory report which fails to identify organisms from cultures taken.2 Experience soon teaches that when challenged by a well assessed history, a negative slide report should itself be rejected as suspect.3'11 He soon learns that a high index of suspicion, rather than the identification of organisms cultured on media, should determine his course of management. Sooner or later he accepts as a practical axiom that, "a woman suspected is a woman to be persuaded to treatment. " 4'9'12 While the problem presented by an asymptomatic, unsuspected female carrier has been fully recognized and is receiving increased attention, little has been introduced to make her more readily identifiable. Public clinics with facilities for mass screening have not been an effective answer. 1I PATHOGENESIS
Its pathogenesis in the female, differs from that in the male.' By in large, the urethral
Gonorrhea's Trojan Horse
Vol. 67, No. 6
mucosa in the male penis offers but poor resistance to bacterial assaults. As, a general rule, a male who makes contact with gonorrhea during intercourse usually contracts it.1-3 After an incubation period which may be as brief as one day2 or as prolonged as six weeks,3 he develops and exhibits the well known symptomatology of the "claps.'" Whether a true carrier state, comparable to that reported in the female can be identified in the male, has not as yet been definitely settled. Notwithstanding the many affirming reports, the subjects providing the statistics were not so securely screened as to exclude the possibility of a reasonable doubt. Indeed, the reported studies might well have been done during a subject's prolonged incubation period.' Only when it can be confirmed that the subjects for such a research in whom organisms were found had been quarantined and physically disabled for a considerable length of time and so exclude the possibility of surreptitious contact, can such conclusions be admitted as proof positive. EPIDEMIOLOGY
Incidentally, the significance of a prolonged incubation as an important epidemiological factor, has been largely ignored. Yet, this is perhaps responsible for the greatest spread of the disease. It is during this time that the active male who has been infected and is so infective, being without symptoms to warn him of his condition, can spread the disease. If he is very mobile, he can disseminate it among several females.7 A problem then presents itself with a history of such promiscuity. How to determine which female was the original source of this train of infection, and to which others was it subsequently passed. So the pragmatic slogan for control, "A woman suspected is a woman to be persuaded to treatment." In the context of a public health and community problem, female resistance in gonorrhea is far from being a blessing. The state of apparent immunity represents at best a precarious balance. The potential menace she represents is an incubus to health authorities. Asymptomatology with a gonorrheal in-
469
fection is largely an expression or measure of vaginal mucosal resistance.8 The specialized epithelial cells6 adapted by nature to sustain its traumatic functions of intercourse and the expanding stress of the emerging infant at childbirth, are not readily vulnerable to bacterial assaults. They present a highly resistant barrier to penetration by the cocci. Without such an invasion, the vascular system cannot be compromised. Toxins cannot enter the blood stream to provoke the more or less generalized reactions of infection. Apparently, while the gonococci in the vagina can rapidly proliferate, they cannot as readily penetrate.7 So long as the barriers remain impermeable it can be assumed that the pathogens have been contained at the surface of the mucosa. Such a female, therefore, although infective on sexual contact, is free from the syndrome associated with the disease. Her only discomfort may be a local itching and a profuse vaginal discharge. This, then, is the picture of the asymptomatic female carrier. Of course, there are factors which include physiological changes which can destroy or reduce the effectiveness of the epithelial barrier. Invasion would then take place and with it, the sequelae of symptoms. The concept that the disease is an extra systemic condition is supported by the fact that in spite of intensive researches, no reactions in the blood of carriers, specific for gonorrhea infections, have even been discovered. A present day concept widely accepted is that invasion through the adult vaginal mucosa seldom occurs8 and that when the symptomatology of the gonorrhea occurs, it is the sequela to a migration of the cocci through the endocervical canal and penetration of its more vulnerable epithelum into the submucosal and vascular areas.9 It is also asserted that the organisms are seldom to be found in the vagina itself but must be sought for at the cervix, the endocervical canal and the orifice of the urethra. Practical experience discounts such an assumption since men with short penises have never discovered a bio-physical immunity to being infected. MANAGEMENT
This writer challenges the rationale of
470
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
management usually recommended" 12 in which systemic therapy-pills and shots, are exclusively used. If it were to be accepted that an absence of symptomatology is the indication that the circulatory system has not been invaded by these virulent pathogens, but for all practical purpos'es they have been restrained and isolated on the surface of an unpenetrated mucosal epithelium beyond the vascular ramifications, then it becomes difficult to understand a rationale in which the agents for bacteriolysis are being released in the blood stream. An anology, admittedly strained, would be to recommend systemic therapy for such purely surface conditions as pediculosis pubis and capitis. This writer has as his preferred routine, the prescribing of bactericidal suppositories and douches. The suppositories are inserted vaginally at bed time. Every introduction subsequent to the first is preceeded by douching. This treatment is continued for 14 days. Oral antibiotics are also prescribed, but these, chiefly as a concession to a "just in case" possibility. It is interesting that every authority whose article this writer has examined, tactily and inferentially endorses the effectiveness of this approach. They do so, when they all warn that douching8,10 before cultures are taken, should be forbidden since by this, the organisms sought can be destroyed and washed away. This treatment is effective, inexpensive and painless-salient factors that commend themselves when the patient, for whom treatment is being recommended, has no conscious discomfort to urge her to make any unusual sacrifice. Ignoring any moral imperative, conceding only to what is realistic and pra,gmatic, it can be said that no responsible person who has been properly informed should contract gonorrhea even after an exposure. Gonorrhea is as preventable as it is curable. A generous warm soapy shower immediatly after intercourse with the genitalia well lavaged can provide the most effective anti-venereal protection available. If every Public Health Program, every private physician who treats such cases were to stress and propagate this, the most significant link that consumates the vicious cycle of infection can be broken.
NOVEMBER, 1975
Every Cassanova should be advised to accept this as a creed and implement it as an indispensable ritual that concludes every ecstatic climax. SUMMARY
Gonorrhea is curable. It is preventable. Yet, as a community health menace, it has continued to defy every effort organized by Public Health authorities for its control. One factor that has reduced the effectiveness of the Public Health programs has been the non-cooperation of private practising physicians in not reporting their cases, so that the infecting contacts can be investigated. A more significant factor is the unsuspected asymptomatic female carrier who unwittingly disseminates the infection. The mucosal cells of the female vagina differ histologically as well as physiologically from its functional counterpart, the cells of the male urethra. These differences determine the fact that while the epithelium of the vagina is highly resistant to bacterial penetration and invasion, the urethral mucosa is very vulnerable. A concept presented is that an infectious asymptomatic state represents a condition in which the pathogenic agents have been contained on a surface beyond the circulatory ramifications. On this basis, the writer challenges the management rationale which recommends systemic therapy-pills, shots-for the lysing of extra systemic organisms. The writer advises that the use of elementary hygienic practices- soapy shower bath immediately after intercourse with genitalia well lavaged can provide -almost complete prophylaxis against the gonococcus. LITERATURE CITED
1. WENDELL, R. Gonorrhea Today. J. of Urol., 11: 374-733, 1974. 2. LIGHTFOOT, R. and E. GOTSCHLICH. Gonococcal Disease. Am. J. Med., 56: 347-356, 1974. 3. CIARK, D. Changing Concepts in Diagnosis and Management. Clin. Ob. Gyn., 16: 3-20, 1974. 4. SCHROETER, A. and C. PAZIN. Gonorrhea-Diagnosis and Treatment. Ann. Int. Med., 72: 553-559, 1971.
(concluded on page 494)
494
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
associations and specialty societies representing medical and other health care providers. The guidelines are to include standards concerning the appropriate supply, distribution and organization of health resources. Priority consideration is to be given to ten items specified in the law. These are: Primary care services for medically underserved populations, especially in rural or economically depressed areas. Development of multi-institutional systems for coordinating or consolidating institutional health services. Developing medical group practices, health maintenance organizations and other organized systems for providing health care. Training and increasing utilization of physician assistants, especially nurse clinicians. Developing multi-institutional arrangements for sharing support services. Promoting activities to achieve improved quality in health
services. The development by health service institutions of the capacity to provide various levels of care on a geographically integrated basis. Promoting activities for preventing disease, including studies of nutritional and environmental factors affecting health and the provision of preventive health care services. Adopting uniform cost accounting and other improved management procedures for health service institutions. Developing effective methods of educating the general public concerning proper personal health care and effective use of available health services.
PLANNING METHODS AND TECHNOLOGY P.L. 93-641 provides authorization and a detailed structure for health planning to develop in this country. Yet that structure alone will not create effective planning if it is not built on a strong technical and methodological base. That base is almost nonexistent today. Our knowledge of how best to plan for health services at the community level, how medical care effects the health status of people, how data can be used to affect planning decisions, and how to measure the relative effectiveness of different health programs or system intervention is extremely underdeveloped. In the discussion of the "how to" of health planning, many
NOVEMBER, 1975
questions are raised, yet few answers are available. The answers to those planning questions must be found if health planning is to be successful in affecting the health status of people and the efficiency and effectiveness of the health system in dealing with health problems. A massive effort is being mounted to improve the methods that are available to make planning decisions. Similarly, effort will be expended in developing a strategy and mechanisms to assure the adoption of new knowledge as it is developed. As the responsibility of health palnning agencies increases so does the need for better methods to meet those responsibilities. Public Law 93-641 recognizes the need for such a program. The legislative requirements for this planning methods development and technical assistance program can be grouped as follows: Provision of assistance in developing agency plans and approaches to planning various types of health services; Development of technical materials including methodology, policies, and standards appropriate for use in health planning; Specification of the minimum data needed to describe the status of the residents of a health services area and the determinants of such status, the status of the health resources and services of a health service area, and the use of health resources and services within the area; Development of guidelines for the organization and operation of HSA's and State agencies; Establishment of a National Health Planning Information Center which will facilitate the exchange of information concerning health services, health resources and health planning and resources development practice and methodology; Development of planning approaches, methodologies, policies and standards consistent with the guidelines recommended by the National Council for Health Policy; and Provision of other technical assistance as may be necessary in order that these agencies may properly perform their functions. The developmental and technical assistance activities will be carried out by the Department directly and through grants and contracts. In addition to these activities, the Secretary is required to assist in meeting the costs of planning, developing, and operating centers for multi-disciplinary health planning development and assistance. A minimum of five such centers will be in operation by June 30, 1976. The centers will be distributed geographically across the country to provide technical and consulting assistance as required by the HSAs and State agencies.
(Broomes, from page 470) 5. LENZ, P. The Woman. Am. J. Nursing, 71.4: 716-719, 1971. 6. SCHROETER, A. and J. LUCAS. Gonorrhea-Diagnosis and Treatment. Ob. Gyn., 39.2: 276-284, 1974. 7. LUCAS, J. The National Venereal Disease Problem.. Med. Clinics N. Amer., 56.5: 10731086, 1972. 8. HART, M. Gonorrhea in Women. J.A.M.A., 216: 1609-1611, 1971.
9. PARISER, H. Asymptomatic Gonorrhea Med. Clinics N. Amer., 56.5: 1127-1132, 1972. 10. KING K. and G. COUNTS and N. BEATHY. Disseminated Gonoccal Infections. Ann. Int. Med., 74.6: 979-991, 1971. 11. FUMARA, N. The Diagnosis and Treatment of Gonorrhea. Med. Clinic. N. Amer., 50.5: 11051113, 1972. 12. HENDERSON, R. Recommended Treatment Schedule for Gonorrhea. Arch. Derm., 111: 317320, 1975.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
NOVEMBER, 1975
Gonorrhea's Trojan Horse: The Asymptomatic Female Carrier EDWARD L. C. BROOMES, M.D., Lakeside Medical Clinic, East Chic-ago, Indiana
Gonorrhea is a curable disease. Effective treatments that are almost specific are available. The results are usually predictable. Yet, paradoxically, in terms of a public health and epidemiological problem it has defied every effort for control.'1-1 Its rising incidence, attested by available statistics,1 makes self evident this failure. The fact that very few physicians in their private practice report their "social disease" cases, contributes largely to this frustration and reduces every officially published statistic to the status of an educated guess.2 For reasons that should be obvious, most cases of venereal disease are seen in private practice and these by physicians who are in general practice.3 These physicians, then form the front line, both in the attack and defense in any anti-venereal campaign. Because of a still existing social stigma and the readily understood threat to marital harmony, not many individuals, even when indigent, seek treatment in public clinics because their identities may be exposed. In the ambience of confidentiality associated with the office of the private practitioner, is to be found the key to any successful anti-venereal program. Physicians who do not participate directly in the community program, can still make a striking and effective contribution. However, this requires that they maintain a high index of awareness 4'8 as to the female carrier. This must be expressed as a serious concern, and demonstrated by a pragmatic but tactful cynicism in investigating the suspected contact, who must first be identified and then induced or persuaded to be examined and treated. To the tactful and considerate physician, this would seldom present a difficulty. The opinions expressed in this paper are
the products of an observation that extends over 30 years of general practice in a largely ghetto area, in one of the most industrialized cities in the Midwest. The clientele embraced an ethnic spectrum of whites, blacks, and Latins. Gonorrhea and its complications have been and still remain a very frequently treated disease in the practice. As a consequence of these credentials, the writer feels entitled to express opinions even when they contradict popularly held and taught concepts. Early in his experience the physician is struck by a singular observation. Seldom did the female, "fingered" by his patient as the "contact", display any of the symptoms or stigmata of the disease. He is further perplexed when a negative pelvic examination of the contact is supported by a laboratory report which fails to identify organisms from cultures taken.2 Experience soon teaches that when challenged by a well assessed history, a negative slide report should itself be rejected as suspect.3'11 He soon learns that a high index of suspicion, rather than the identification of organisms cultured on media, should determine his course of management. Sooner or later he accepts as a practical axiom that, "a woman suspected is a woman to be persuaded to treatment. " 4'9'12 While the problem presented by an asymptomatic, unsuspected female carrier has been fully recognized and is receiving increased attention, little has been introduced to make her more readily identifiable. Public clinics with facilities for mass screening have not been an effective answer. 1I PATHOGENESIS
Its pathogenesis in the female, differs from that in the male.' By in large, the urethral
Gonorrhea's Trojan Horse
Vol. 67, No. 6
mucosa in the male penis offers but poor resistance to bacterial assaults. As, a general rule, a male who makes contact with gonorrhea during intercourse usually contracts it.1-3 After an incubation period which may be as brief as one day2 or as prolonged as six weeks,3 he develops and exhibits the well known symptomatology of the "claps.'" Whether a true carrier state, comparable to that reported in the female can be identified in the male, has not as yet been definitely settled. Notwithstanding the many affirming reports, the subjects providing the statistics were not so securely screened as to exclude the possibility of a reasonable doubt. Indeed, the reported studies might well have been done during a subject's prolonged incubation period.' Only when it can be confirmed that the subjects for such a research in whom organisms were found had been quarantined and physically disabled for a considerable length of time and so exclude the possibility of surreptitious contact, can such conclusions be admitted as proof positive. EPIDEMIOLOGY
Incidentally, the significance of a prolonged incubation as an important epidemiological factor, has been largely ignored. Yet, this is perhaps responsible for the greatest spread of the disease. It is during this time that the active male who has been infected and is so infective, being without symptoms to warn him of his condition, can spread the disease. If he is very mobile, he can disseminate it among several females.7 A problem then presents itself with a history of such promiscuity. How to determine which female was the original source of this train of infection, and to which others was it subsequently passed. So the pragmatic slogan for control, "A woman suspected is a woman to be persuaded to treatment." In the context of a public health and community problem, female resistance in gonorrhea is far from being a blessing. The state of apparent immunity represents at best a precarious balance. The potential menace she represents is an incubus to health authorities. Asymptomatology with a gonorrheal in-
469
fection is largely an expression or measure of vaginal mucosal resistance.8 The specialized epithelial cells6 adapted by nature to sustain its traumatic functions of intercourse and the expanding stress of the emerging infant at childbirth, are not readily vulnerable to bacterial assaults. They present a highly resistant barrier to penetration by the cocci. Without such an invasion, the vascular system cannot be compromised. Toxins cannot enter the blood stream to provoke the more or less generalized reactions of infection. Apparently, while the gonococci in the vagina can rapidly proliferate, they cannot as readily penetrate.7 So long as the barriers remain impermeable it can be assumed that the pathogens have been contained at the surface of the mucosa. Such a female, therefore, although infective on sexual contact, is free from the syndrome associated with the disease. Her only discomfort may be a local itching and a profuse vaginal discharge. This, then, is the picture of the asymptomatic female carrier. Of course, there are factors which include physiological changes which can destroy or reduce the effectiveness of the epithelial barrier. Invasion would then take place and with it, the sequelae of symptoms. The concept that the disease is an extra systemic condition is supported by the fact that in spite of intensive researches, no reactions in the blood of carriers, specific for gonorrhea infections, have even been discovered. A present day concept widely accepted is that invasion through the adult vaginal mucosa seldom occurs8 and that when the symptomatology of the gonorrhea occurs, it is the sequela to a migration of the cocci through the endocervical canal and penetration of its more vulnerable epithelum into the submucosal and vascular areas.9 It is also asserted that the organisms are seldom to be found in the vagina itself but must be sought for at the cervix, the endocervical canal and the orifice of the urethra. Practical experience discounts such an assumption since men with short penises have never discovered a bio-physical immunity to being infected. MANAGEMENT
This writer challenges the rationale of
470
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
management usually recommended" 12 in which systemic therapy-pills and shots, are exclusively used. If it were to be accepted that an absence of symptomatology is the indication that the circulatory system has not been invaded by these virulent pathogens, but for all practical purpos'es they have been restrained and isolated on the surface of an unpenetrated mucosal epithelium beyond the vascular ramifications, then it becomes difficult to understand a rationale in which the agents for bacteriolysis are being released in the blood stream. An anology, admittedly strained, would be to recommend systemic therapy for such purely surface conditions as pediculosis pubis and capitis. This writer has as his preferred routine, the prescribing of bactericidal suppositories and douches. The suppositories are inserted vaginally at bed time. Every introduction subsequent to the first is preceeded by douching. This treatment is continued for 14 days. Oral antibiotics are also prescribed, but these, chiefly as a concession to a "just in case" possibility. It is interesting that every authority whose article this writer has examined, tactily and inferentially endorses the effectiveness of this approach. They do so, when they all warn that douching8,10 before cultures are taken, should be forbidden since by this, the organisms sought can be destroyed and washed away. This treatment is effective, inexpensive and painless-salient factors that commend themselves when the patient, for whom treatment is being recommended, has no conscious discomfort to urge her to make any unusual sacrifice. Ignoring any moral imperative, conceding only to what is realistic and pra,gmatic, it can be said that no responsible person who has been properly informed should contract gonorrhea even after an exposure. Gonorrhea is as preventable as it is curable. A generous warm soapy shower immediatly after intercourse with the genitalia well lavaged can provide the most effective anti-venereal protection available. If every Public Health Program, every private physician who treats such cases were to stress and propagate this, the most significant link that consumates the vicious cycle of infection can be broken.
NOVEMBER, 1975
Every Cassanova should be advised to accept this as a creed and implement it as an indispensable ritual that concludes every ecstatic climax. SUMMARY
Gonorrhea is curable. It is preventable. Yet, as a community health menace, it has continued to defy every effort organized by Public Health authorities for its control. One factor that has reduced the effectiveness of the Public Health programs has been the non-cooperation of private practising physicians in not reporting their cases, so that the infecting contacts can be investigated. A more significant factor is the unsuspected asymptomatic female carrier who unwittingly disseminates the infection. The mucosal cells of the female vagina differ histologically as well as physiologically from its functional counterpart, the cells of the male urethra. These differences determine the fact that while the epithelium of the vagina is highly resistant to bacterial penetration and invasion, the urethral mucosa is very vulnerable. A concept presented is that an infectious asymptomatic state represents a condition in which the pathogenic agents have been contained on a surface beyond the circulatory ramifications. On this basis, the writer challenges the management rationale which recommends systemic therapy-pills, shots-for the lysing of extra systemic organisms. The writer advises that the use of elementary hygienic practices- soapy shower bath immediately after intercourse with genitalia well lavaged can provide -almost complete prophylaxis against the gonococcus. LITERATURE CITED
1. WENDELL, R. Gonorrhea Today. J. of Urol., 11: 374-733, 1974. 2. LIGHTFOOT, R. and E. GOTSCHLICH. Gonococcal Disease. Am. J. Med., 56: 347-356, 1974. 3. CIARK, D. Changing Concepts in Diagnosis and Management. Clin. Ob. Gyn., 16: 3-20, 1974. 4. SCHROETER, A. and C. PAZIN. Gonorrhea-Diagnosis and Treatment. Ann. Int. Med., 72: 553-559, 1971.
(concluded on page 494)
494
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
associations and specialty societies representing medical and other health care providers. The guidelines are to include standards concerning the appropriate supply, distribution and organization of health resources. Priority consideration is to be given to ten items specified in the law. These are: Primary care services for medically underserved populations, especially in rural or economically depressed areas. Development of multi-institutional systems for coordinating or consolidating institutional health services. Developing medical group practices, health maintenance organizations and other organized systems for providing health care. Training and increasing utilization of physician assistants, especially nurse clinicians. Developing multi-institutional arrangements for sharing support services. Promoting activities to achieve improved quality in health
services. The development by health service institutions of the capacity to provide various levels of care on a geographically integrated basis. Promoting activities for preventing disease, including studies of nutritional and environmental factors affecting health and the provision of preventive health care services. Adopting uniform cost accounting and other improved management procedures for health service institutions. Developing effective methods of educating the general public concerning proper personal health care and effective use of available health services.
PLANNING METHODS AND TECHNOLOGY P.L. 93-641 provides authorization and a detailed structure for health planning to develop in this country. Yet that structure alone will not create effective planning if it is not built on a strong technical and methodological base. That base is almost nonexistent today. Our knowledge of how best to plan for health services at the community level, how medical care effects the health status of people, how data can be used to affect planning decisions, and how to measure the relative effectiveness of different health programs or system intervention is extremely underdeveloped. In the discussion of the "how to" of health planning, many
NOVEMBER, 1975
questions are raised, yet few answers are available. The answers to those planning questions must be found if health planning is to be successful in affecting the health status of people and the efficiency and effectiveness of the health system in dealing with health problems. A massive effort is being mounted to improve the methods that are available to make planning decisions. Similarly, effort will be expended in developing a strategy and mechanisms to assure the adoption of new knowledge as it is developed. As the responsibility of health palnning agencies increases so does the need for better methods to meet those responsibilities. Public Law 93-641 recognizes the need for such a program. The legislative requirements for this planning methods development and technical assistance program can be grouped as follows: Provision of assistance in developing agency plans and approaches to planning various types of health services; Development of technical materials including methodology, policies, and standards appropriate for use in health planning; Specification of the minimum data needed to describe the status of the residents of a health services area and the determinants of such status, the status of the health resources and services of a health service area, and the use of health resources and services within the area; Development of guidelines for the organization and operation of HSA's and State agencies; Establishment of a National Health Planning Information Center which will facilitate the exchange of information concerning health services, health resources and health planning and resources development practice and methodology; Development of planning approaches, methodologies, policies and standards consistent with the guidelines recommended by the National Council for Health Policy; and Provision of other technical assistance as may be necessary in order that these agencies may properly perform their functions. The developmental and technical assistance activities will be carried out by the Department directly and through grants and contracts. In addition to these activities, the Secretary is required to assist in meeting the costs of planning, developing, and operating centers for multi-disciplinary health planning development and assistance. A minimum of five such centers will be in operation by June 30, 1976. The centers will be distributed geographically across the country to provide technical and consulting assistance as required by the HSAs and State agencies.
(Broomes, from page 470) 5. LENZ, P. The Woman. Am. J. Nursing, 71.4: 716-719, 1971. 6. SCHROETER, A. and J. LUCAS. Gonorrhea-Diagnosis and Treatment. Ob. Gyn., 39.2: 276-284, 1974. 7. LUCAS, J. The National Venereal Disease Problem.. Med. Clinics N. Amer., 56.5: 10731086, 1972. 8. HART, M. Gonorrhea in Women. J.A.M.A., 216: 1609-1611, 1971.
9. PARISER, H. Asymptomatic Gonorrhea Med. Clinics N. Amer., 56.5: 1127-1132, 1972. 10. KING K. and G. COUNTS and N. BEATHY. Disseminated Gonoccal Infections. Ann. Int. Med., 74.6: 979-991, 1971. 11. FUMARA, N. The Diagnosis and Treatment of Gonorrhea. Med. Clinic. N. Amer., 50.5: 11051113, 1972. 12. HENDERSON, R. Recommended Treatment Schedule for Gonorrhea. Arch. Derm., 111: 317320, 1975.
