Book Review

The Hidden Epidemic: Confronting sexually transmitted diseases

N Engl J Med 1997; 337:1177-1178October 16, 1997

Article

The Hidden Epidemic: Confronting sexually transmitted diseases
Edited by Thomas R. Eng and William T. Butler. 432 pp. Washington, D.C., National Academy Press, 1997. $39.95. ISBN: 0-309-05495-8

Each year 12 million new cases of sexually transmitted diseases, including 3 million in teenagers, occur in the United States, with population rates higher than in any other developed country. In 1995, 5 of the 10 most frequently reported diseases in the United States were sexually transmitted, accounting for 87 percent of the diseases reportable to the Centers for Disease Control and Prevention. The collective toll of these diseases on individuals and communities is enormous. In addition to the morbidity and mortality associated with sexually transmitted human immunodeficiency virus (HIV) infections, sexually transmitted diseases cause serious complications, including cancer, pelvic inflammatory disease, infertility, ectopic pregnancy, spontaneous abortions, stillbirth, low birth weight, congenital infections, and death. These diseases also increase the potential for sexual transmission of HIV infection, and effective treatment and prevention of them can dramatically reduce HIV transmission.

The economic costs of sexually transmitted diseases further provide a relative criterion for determining the magnitude of the problem. Excluding the cost of HIV infection and AIDS, it was estimated that in 1994 the total cost of selected common sexually transmitted diseases was $10 billion. The annual cost of sexually transmitted HIV infection raises the overall cost of sexually transmitted diseases to nearly $17 billion. Although most of these diseases are readily preventable, only $230 million are expended annually on their prevention and $105 million on biomedical and clinical research. With only modest increases in funds for prevention, treatment, and research, enormous savings can be achieved.

Despite the overwhelming evidence of their medical, economic, social, and cultural impact, sexually transmitted diseases remain epidemic and hidden from mainstream society. Although all persons are susceptible to such diseases, some remain at greater risk because of poverty, substance abuse, inadequate access to health care, and other social and cultural factors. Fundamentally, it is the inability of our society to discuss and confront issues regarding sexuality that has led to ignorance about the problem, which in turn incapacitates the public health efforts to control sexually transmitted diseases. In a recent survey of women, two thirds of those surveyed knew nothing or very little about sexually transmitted diseases other than AIDS. Only 11 percent of teenagers surveyed reported receiving information about such diseases from their parents, and yet 70 percent of 12th-grade students were sexually active and 27 percent had had sexual relations with four or more partners each. Even in the medical arena, education and knowledge about the clinical care of patients with sexually transmitted diseases remains inadequate. Only one third of medical schools currently offer students a clinical elective in sexually transmitted diseases or HIV infection and AIDS. Unfortunately, with the increasing shift in health care to health maintenance organizations and with decreased public health funding for clinics that treat sexually transmitted diseases, further deterioration of the clinical treatment and prevention of such diseases is likely to occur.

As a result of the inability of the public and private health sectors to confront these problems adequately, the Institute of Medicine convened a 16-member expert committee on the prevention and control of sexually transmitted diseases specifically to examine the epidemiologic dimensions of, and the factors contributing to, the epidemic in the United States, assess the effectiveness of current public health programs to control these diseases, and provide directions for future public health programs, policy, and research. Over an 18-month period, a comprehensive blueprint entitled The Hidden Epidemic: Confronting Sexually Transmitted Diseases emerged, which is centered on a vision of how to provide “an effective system of services and information that supports individuals, families, and communities in preventing STDs, including HIV infection, and ensures comprehensive, high-quality STD-related health services for all persons.” In this report, the committee outlines the current problem of the epidemic in the United States. By recognizing the deficiencies and by incorporating the positive attributes of the current system, the committee designed a new, integrated national system for the prevention and control of sexually transmitted diseases. Four major strategies were formulated to accomplish this goal, including ways to overcome barriers to healthy sexual behaviors; to develop strong leadership, strengthen investment, and improve information systems for the prevention of sexually transmitted disease; to design and implement innovative services for adolescents and underserved populations; and to ensure access to and the quality of clinical services.

This book should be required reading for all students and professionals in the fields of public health, epidemiology, infectious diseases, family practice, and general medicine, as well as for directors of health maintenance organizations and political leaders who make funding decisions regarding public health. It does not provide guidelines for the diagnosis and treatment of individual sexually transmitted diseases. Rather, it provides an in-depth description of strategies for building a better health care system aimed at controlling such diseases.

The chapters are well written and comprehensive, and they provide excellent documentation. If the recommendations were implemented today, the impact on the control of sexually transmitted diseases would be dramatic. On an individual level there would be a marked improvement in medical care, and on a societal level there would be considerable savings in terms of medical expenditures for sequelae related to sexually transmitted diseases. Unfortunately, it is unlikely that the funds needed to implement all these strategies will materialize. Thus, it is regrettable that the recommendations were not listed in order of their priority and that funding responsibilities were not discussed. Nevertheless, the committee accomplished its goal of redesigning a national agenda for improved treatment and prevention of sexually transmitted diseases. The next step is convincing policymakers and those responsible for financing health care that these strategies are necessary and should be implemented. I strongly hope that persons in such leadership positions read this book and act on its recommendations. To continue on the current path of ignorance about sexually transmitted diseases will only result in an escalation of the epidemic.

Thomas S. Quinn, M.D.
National Institute of Allergy and Infectious Diseases, Baltimore, MD 21205-2196