OUTLINE OF VENEREAL DISEASE CONTROL PROCEDURES FOR NON-COMMISSIONED VENEREAL DISEASE CONTROL OFFICERS Office of the Surgeon, Headquarters, Army Air Forces Central Flying Training Command, Randolph Field, Texas INDEX FOREWORD . 1 iNTRObUCTION 2 DUTIES OF VENEREAL DISEASE CONTROL NON- COMMISSIONED OFFICERS . , . . 4 THE VENEREAL DISEASES 5 PROPHYLAXIS 11 COMMON FALLACIES IN VENEREAL DISEASE 14 STATISTICAL METHODS . . 19 EVALUATION OF THE LOCAL SITUATION 22 SUBSTITUTIVE ACTIVITIES’ 24 EDUCATIONAL METHODS 26 THE PROSTITUTION PROBLEM 31 THE PLANNED PROGRAM 33 REVIEW .34 REGULATIONS PERTAINING TO VENEREAL DISEASE 35 Page FOREWORD You have been charged with the responsibility of promoting methods of controlling the venereal disease (VD) rate in your organization by your appointment to be venereal disease control non-commissioned offi- cer (VDCNCO). This manual is designed to assist you as a reference book in discharging this duty to which you have set yourself. It is important to maintain proper relationships in carrying out any program that is to succeed. The Unit Commander is responsible for the VD rate of his organization. It is extremely important to remember that there is one authorized head of each organization; the commanding officer is charged with the entire responsibility of all activities in the unit; the final decision must always be his. If you understand this, you will be able to assume your rightful places in the work of the unit, and be- cause of your specialized training you will be able to be of assistance to the Commanding Officer if your program is.well planned. You must appreciate your relationship to your fellow Non-Coms, Others in 'your organization are highly trained to do their particular jobs; ac- quaint yourself with their work and problems, but let each man "run" his own business. Take an intelligent part in ail discussions and attempt to familiarize others with your program and aims. A feeling of friendly co- operation by your fellow workers will inspire you and greatly assist you in the accomplishment of your purpose. In your zeal to decrease your unit VD rate, do not become obnoxious—always be "one of the boys" but never try to be the "star". Intelligent help by your fellow Non-Coms will aid you materially—the moral support of the First Sergeant and Pla- toon Leaders will "sell" your program to your men. Always remember that your stripes carry an added responsibility to the organization as a whole. If you will remember the early days of your service you will think of the things you despised most in certain Non-Coms. Try to see yourself as the "buck private" sees you—he is the one who really needs most of our help. Do not be so "haughty" that you drive him away before he can hear your message. Do not be paternalistic, but have a genuine interest in him and his problems, offering'every assistance possible but do not force yourself upon him. Assume the proper relationship to the others engaged in this work. Friendly competition, mutual counselling, and frequent conferences will lead to the best benefit of all in the VD control program. One may consider this to be a hopeless course, but we have asked your company commanders to carefully select a group of Non-Coms into whose hands we are trusting the torch of knowledge so that the members of this group may work intelligently with all of the members of the Command, "Knowledge is power"—arouse a VD consciousness in your platoons and squads—in your men—then vdth the proper facts, fully inform them of the solution of their problem—you know very, well that any smart man will use, true 'knowledge for his own good—do not withhold it from him—he will seek it if you will let him taste qf it. This brochure arid these lec- tures are to endow you vdth a foundation of knowledge so that you can build yourself into a very useful member of your organization. INTRODUCTION The importance of the venereal disease problem is attested by the fact that during the last war the American troops lost 7,500,000 days to this scourge in eighteen (IB) months. There were 157, 146 more vene- real disease casualties than all battle injuries to our men. tie lost enough time to have 20 infantry divisions on the battlefield for an en- tire year, or 240 divisions on the field for a month. The VD problem has always haunted all armies in war time. The following graph shows the picture for our army from 1840 to 1940. The results of the work of selected Non-Coms will show a definite decrease during this war over all previous wars. Naturally the question arises as to whether or not this is a true pic- ture. We shall study rates and graphs in a later chapter and then we can understand that by using a rate we may compare one group with another. We immediately ask if this is .n usual picture. The following graph will give the comparison of the white and colored rate for the Army during peace time, showing that our colored rate is much higher than the colored rate for the Army as a whole. During the year 1942 there wore 35*660 man days lost due to venereal diseases in this Command, The rate for the members of the colored organizations has been 10 to 20 times as great as the rate for the white troops. An all colored field at Tuskegee has had a rate consistently near our white rate for many months. If we set our minds to controlling the problem, we can handle it without any difficulty. The VDCNCOs are charged with that responsibility. The venereal diseases are important to the Army because each one of us spends just so much time for training while we are on the field here— if part of that time is spent in the Hospital, we loss that training and are not able to take care of ourselves when we get into ’’the fight”. The venereal diseases are important to our winning the Victory be- cause many men are getting the venereal diseases in the Combat Zone, When a man gets into or near the War Zone, all of his time and strength is needed for fighting and for his own defense against the enemy—the ve- nereal'.diseases can be prevented so we must keep our men well where they are needed. The venereal diseases do have very bad effects upon the health, home, and happiness of the man himself. In later lectures we shall outline what the venereal diseases are and what they do to the individual and his fam- ily. The two principal health problems of the negro race are: tuberculosis and the venereal diseases. It is our hope that you men will return to* your home communities after the war and help your neighbors to understand how to handle these scourges scientifically'so that they may be eradicated. Mark- ed progress has already been made in the control of tuberculosis, now—the control of venereal disease can and must show progress. This is a challenge to you men as especially selected Non-Coms in the Array i DUTIES OF VENEREAL DISEASE CONTROL NON-COMMISSIONED OFFICERS The fundamental basis for your work will be to assist the Command- ing Officer of your organization in controlling the venereal disease rate in your organization. All of your programs must be discussed with him and approved by him before they are started. If there is a venereal disease control officer on the field* your work will bo under his direction for his work is under the leadership of the Commanding Officer of the station. 1. Education of the soldier. a. Give to every soldier all possible information relative to the venereal diseases, their complications, and results. b, Use the most effective psychological appeals for the reduc- tions of the rate in the group with which you are working. c. Design proper educational efforts that will be effective among your troops. d. Form a venereal disease consciousness among the men, appeal- ing to personal, racial, and military pride. e. Keep competitive rates of organizations for your men. Keep charts and graphs to show whether your organization is progressing upward or downward in its control of tnis rate. f. Keep venereal disease posters in places where men can see them. Change posters frequently, helping those men who cannot read to under- stand the contents of the posters. £, Dispel all fallacies. 2, Plan and organized and continuing program for your men. 3. Promote social, athletic, and recreational programs for the soldiers on the post. 4* Help your men to find suitable recreational facilities in the community in which they live. 5. Encourage prophylaxis among your men. Supervise the distribution of the prophylactic materials; make sure adequate supplies are always on hand. Encourage intoxicated soldiers to take prophylaxis, being diploma- tic and attempting to help them while under the influence of alcohol. Demonstrate the use of the prophylactic materials that are available to your men. 6, Provide liasion between the troops and your company officers so that you may be in position to point out any conditions that you may consider to be harmful to the health, welfare, and morale of the men. Maintain contact with all patients who are under treatment or observation to be sure unin- terrupted treatment is followed. THE VENEREAL DISEASES The venereal diseases are usually contracted from sexual Intercourse* These diseases are usually acute, in that they develop rapidly and because they may give a groat amount of discomfort at the time they are present. Each disease will be discussed separately and the length of infection will be described. • '• It may be stated positively that medical science has disproved the toilet seat as a danger in the venereal question. A baby may be born with gonorrhea of the eyes which it gets from its mother. A child may be given syphilis wnile its mother carries it before it is born. It is possible to get syphilis by kissing an individual who has sores of syphilis in or around the mouth. However, sexual intercourse is the most important way that vene- real diseases are caught. It is important taxanembar that not any sex con- tact will lead to the envelopment of venereal diseases but*.contact wita a diseased person is necessary for an individual to catch the diseases. There are five (5) commonly recognized venereal diseases. These are— Syphilis, Gonorrhea, Chancroid, Lymphogranuloma Venereum, and Granuloma Inguinale. It is important in discussing these diseases with the average layman not to refer to them by the scientific names alone, but to include in the discussion some of the more common names by which these infections are recognized. V*e might list thoee n ines commonly associated with the ve- nereal diseases: 1. Syphilis—(a) Pox (b) Syph (c) Chancre (d) Sore (e) Haircut (f) Bad Blood (g) Lues 2. Gonorrhea—(a) Clap (b) Strain (c) Running Range (d) Leak in the Dyke (e) Backache (f) vVhitos (g) Leukorrhea (h) Gloat (i) Dose (3) A Case 3. Chancroid—(a) Blueballs (b) Swollen Gland (c) Kernel (Kennel) (d) Soft Chancre 4. Lymphogranuloma Venereum—(Scientifically this is also known as Lymphopathia Venereum, Lymphogranuloma Inguinale and Climatic Buboe) 5. Granuloma Inguinale—There appears to be no common name for Granuloma Inguinale becuase this and Lymphogranuloma Venereum are confused with other.conditions, <* It is necessary that the importance of these venereal diseases be re- cognized in the mind, of the average man. These diseases have not been con- sidered to be any more important than a common cold, and frequently boys have thought that they are not men until t/iey have had at least one vene- real diseases. This idea must be forever cleared from their minds. There arc three major considerations relative to the importance of the venereal diseases: 1, To the Army, a. A tremendous amount of time is lost from the training program of many enlistee men because of the saboteurs called venereal diseases. If a man is unable to learn all that is necessary to be learned during the training program he cannot bo a successful soldier. If a man is in the hospital vdth a simple case of gonorrhea, but yet misses out in his train- ing on the use and care of the gasmask, he may lose his life while in battle because he lost this amount of training. b, Reports have boon received which indicate that many men arc con- tracting venereal diseases in the area where the fighting is thick. It is extremely important that all of the men on the fighting front be effec- tive at all times. If many men are put out of the battle due to the simple venereal diseases we may easily lose the battle. 2, To the Individual, a, d'he health of the individual may be very definitely damaged by the venereal diseases, and his life may be shortened by a number of years. The effects on the body mil be considered under the discussion of each of the diseases, *'‘e may appeal to the patriotism or pride of the individual, but our most effective appeal may bo pointed out to him as to how these diseases may affect him as an individual. b. It will be noted later t.iat trie happiness of the. individual may be greatly endangered by the ravages of these preventable diseases. c. The home of the individual may be destroyed by the effect of these diseases if the man’s wife has to have serious operations oecause he has taken a venereal infection home from the war; and the family may be devoid of children if either the husband or the wife has contracted a venereal disease. Blind, sickly, paralyzed children sometimes are born into the homes of those who have contracted venereal diseases. 3, To the Community, a. Hospitals for the blind, the lame, and the insane must be kept by the community because men get venereal diseases which .sap their strength. b. Many people in the community are unable to work because.* the vene- real diseases have taken their vitality. c. The health of any.race or any country or community deteimines the progress made by that group toward its ultimate goal in civilization, we cannot expect aa rapid a progress with sickly members as we could expect with a,mentally and physically active group. Many pamphlets and books have been written about the venereal diseases, so we shall give hare only a brief summary of each venereal disease. 1, Gonorrhea (Neisserian infection) accounts for about eighty (SO) percent of all of the venereal diseases ad- mitted to the Army hospitals. This disease is caused by a germ called the "gonococcus'* which looks like two coffee-bean shaped "bugs", Which occur together, Tiiese germs lodge in the urinary channel in the man or in the woman. Taay set up an irritation which leads to the formation of many small ab- scesses from which pus flows, A person knows he has gonorrhea by the dis- charge of this thick, yellow pus; also by the fact that he has to pass water frequently during the cay due to the fact that the urine irritates the sore channel and may make the passing of his water painful, •‘■his dis- charge of pus in the woman is frequently known as the "whites". The tender tissues of -the mouth of the womb in the woman also harbor this germ and the woman not know that she is infected, so that it is very easily passed on to anyone who nas sex contact with the infected girl. T ig disease usually comes on in three to five days after the contact. A person may clear up his own discharge with very little or no treat- ment in a period of a few weeks. If not properly treated, he r.ay go on to have a tremendous amount of trouble and complications. If a man reports for treatment early he can bo completely cured with the wonderful new "Sulfa" drugs, but these can be dangerous to the individual so they should be taken only under the strict guidance of a doctor who knows his business, A man may be cured in a period less than a week if he takes his treat- ment early and carefully. Some of the immediate complications of gonorrhea may be marked swelling and pain of the foreskin of the penis. Ihere may be an abscess of the prostate gland which will rupture or may have to be open- ed through the rectum. There may be a very painful swelling of one or both of the testicles, and if this happens the man’'may be sterile the rest of his life (this means that he will be unable to have children). Some people get the pus of the gonorrhea on their hands and from their hands in- to their eyes and may be made blind this way. Some of the old complications of gonorrhea may be listed -as: — Rheumatism, arthritis, chronic prostate trouble, which may lead to cause pain in the back, or there may be a blood poisoning in an occasional case of gonorrhea, with heart damage. In the woman,-we may find an abscess of the tubes and ovaries, so that she may not bear children, or she may have to be operated on to have all the female organs taken out. You can see readily that this is a serious operation. The woman may have abscesses or irritation in her female organs. 2, Chancroid is ordinarily a localized sore which comes on within a week or two after contact with a person who has this disease. It is caused by the germ called the ’’Ducrey Bdcillus,,. This germ, leacs to fin enlarged, ragged, eating sore, that may, if it is not treated properly and early, eat a large portion of the penis away. This germ also settles in the gland of the groin, so that an abscess forms and has to be lanced. This boil discharges pus for a long period of time. More cases of Chancroid are seen in the tropics and sub-tropics than in tae northern part of our country. This is a real danger in this area, and even though it is a localized disease, it may do great damage to the man or wom- an who has this trouble. It certainly can destroy a soldier’s manhood quickly, yet it can be so easily prevented by a little cleanliness—soap and water will kill this germ very quickly if a man will use it in time. 3. Lymphogranuloma Venereum is a disease that is caused by a so called filtrable virus. This disease occurs fre- quently in the tropics and is seen quite frequently in the southern portion of this country. It is only recent- ly that' doctors have been able to find out how to treat this disease successfully. There are still many men who are suffering from tnis condition. This disease leads to a small sore at the point at which the infection enters the body and leads to very painful abscesses of the glands of the groin. Painful swelling for a long period of time in the "privates of the individual" may result from this disease. Not a great deal is known about this condition, except that it is quite widespread in this area and may load to a great deal of disability of sickness. 4. Granuloma Inguinale is another* one of the strange tropical diseases associated with sex contacts. The so called "Do '.-.evan Body" has been found to be the cause of this condition. This disease leads to large sores which turn into proud flesh, and it may lead to large bleeding areas around the sex organs, the thighs, and the rectum. This condition may last for a numb r of years and a patient may im.ve to take treatment for many many months before these sores even begin to heal. Treat- ment must be continued over a long period of time before the patient is finally cured. 5. Syphilis is a disease caused by the "Spirochete", (Treponema Pallidum). This disease at first shows it- self as a local infection but soon gets into the blood and becomes a general body infection. Syphilis may mimic almost every disease known to medical science. It causes a large number of deaths each year. If diag*« nosis is made early and treatment is started and carried on all the way through over a large period of months, a patient can be ex- pected to be cured in nearly 100% of the cases. If a person waits until he has had the disease over a long period of time before he starts treat- ment, he cannot expect to be cured, but may stop the effect of the disease where it is. Many a baby has been born dead or has been born to be an invalid all its life because its mother had syphilis which she gave to her child during pregnancy. Syphilis is divided into several periods. The first period is the PluTr v»*o — rro S'.ut-k "• ■ '•'»• ft* i‘ ‘j-i4 A Mur iv o wc o pi . Primary cr Chancre stage. A small sore comes on c.t the point of contact, which may be the lip if a person kissed a diseases person; may be the fin- ger of a doctor or nurse who was careless in treating a diseased person; may be the sex organs of a person who has had sexual contact with a person who has the disease. This little ulceratea sore usually comes on in a period of from nine (9) to twnnty-one (21) days after exposure. This sore may go away by itself after six weeks time without treatment, but the germs have already gotten into the body. This sore and the sores of the Second- ary stage are very infectious, which means that any person may catch the disease from these sores or lesions. The germ of Syphilis may be seen with the aid of a special miscroscope which shows them to be small, active, corkscrew shaped germs. The second stage of Syphilis is cabled the Secondary Stage. During this time a person may break out in the mouth or in any part of the body, or all over the body, with sores which may be of several different types. They maybe red blotches; ringed shape sores called Mannular lesions"; pimple- like bumps; or scab sores like smallpox. The person is very dangerous to others curing this stage of his disease, and should be quarantined just like a person with smallpox. The bad blood test is always positive by the time the secondary rash breaks out. The person certainly should start his treatment not any later than the time the disease is found at this stage. This phase of the disease may come on just before the chancre heals or may come on any time to six months later. The sores may last for several months. Following the first and second stages of Syphilis, there is a period of inactivity called the Latent Stage. Luring tnis time the blood tost is positive, but that is the only sign of Syphilis in the person’s body, The Syphilis gems are busy attaching themselves to the organs of the body during tais time. This time may last from three years to about twanty- five years. The Latent Stage is the important one for the individual because it is during this time that the disease will cripple or kill him. Soma people will have large eating sores which may eat away the nose; others may deve- lop large ulcers of the legs or other parts of the body. In some people the germs will lodge in their livers, kidneys, or other vital organs of the body, which will make them invalids but will not kill them. At le-.>.st one person out of every four whose Syphilis was not treated, will die a horrible death from the results of the disease. Many of them go insane or "crazy11 and have to be put in a mental institution two to five years be- fore their death. In fact, one person out of every eight or ten who is in the insane asylum is there because he had Syphilis a few years ago. Heart trouble is killing more people today than any other disease. Fifteen people out of every 1000 who die of heart trouble, die as a result of Syph- ilis of the heart or large blood vessels. In your work with your men it is very important to try to help them to keep themselves from getting venereal diseases, but it is just as important to encourage them to report for treatment early if they get the disease and to encourage them to keep taking treatment over a period of months until they are completely cured. After a person is said to be cured, he should continue to have..a blood test; should have a careful physical examination; and should have the fluid from his spine examined to make sure that the disease has not gone to his brain. SYPHILIS can be prevented, SYPHILIS can be cured. SYPHILIS can bo very cangerous. Many testbooks have been written on the venereal diseases and many current journals are published on the subject. Doctor J. E. Moore of Johns Hopkins Hospital, Baltimore, Md,, and Doctor J. H. Stokes of the University of Pennsylvania, have written books on Syphilis; Doctor P. S, Pelouze of the University of Pennsylvania, has written books on Gonorrhea that are among the best. The following three journals are brought to your attention; 1* Venereal disease Information—USPHS, Washington, D.C. 2. Journal of the Public Health Association—1790 Broadway, New York, N.Y, 3. Archives of Dermatology and Syphilolog;, published by the American Medical Association—535 Dearborn St., Chicago, 111, PROPHYLAXIS Prophylaxis is by definition the use of known protective measures against disease; the taking of typhoid fever shots is a prophylactic meas- ure, the same as is the cleaning of the teeth to prevent decay. It should be interesting to your men to realize that they have been following such preventive measures over a long period of time previous to the army ex- perience. The use of measures to prevent venereal disease should be only the continuation of their program of self-protection which they have been following for years. One of the most important functions of the men engaged in venereal disease control, will be that of encouraging the use of prophylaxis, the aemonstrations of the proper use of available prophylactic material, and the constant checking to make sure that prophylactic materials are always freely available within the company for the use of the members of the or- gan! zation, In a subsequent chapter we shall consider the local situation, which will indicate the need for constant thought regarding prophylactics. There are several readily available means of prevention of venereal disease. These are: 1. Continence 2. Use of the condom 3. Station prophylaxis 4. The two-tube individual prophylactic kit 5. Immediate urination and the use of soap and water if no other , means are available. It can be said from a medical viewpoint that sexual intercourse is not necessary and, therefore, our staying away from pernicious sex con- tacts is the most sure way of not getting a venereal disease, but we must recognize that there are many men who have made the decision that they do not choose to follow this pattern of behavior, he must not be so realistic that we will base our program on this fact alone. There are many men who are remaining true to a wife in another area or to a future wife and for these men we need have no concern. There are many men who are going to make sex contacts irrespective of what you or I may say. We must consi- der that it is their privilege to live their own lives as they choose. Our help to them can be in trying to point out the dangers of venereal disease, and the large percentage of infected cases in the area; we should help them to know of the simple measures that are available for their pr- tection and wo should encourage the use of these measures for these men. There are many men who will make sex contacts if there are no other tilings to occupy their time and minds. Our education should help these men, and our program of "Substitutive Activities" is directed in trying to promote fewer sex con tacts as a means of preventing loss of time from venereal diseases. The use of the rubber, or con don, should prevent a large number of cases because of the fact that eighty percent of the venereal cases are gonorrhea. If the rubber is used correctly there is absolutely no possi- bility of getting gonorrhea, even trio ugh the woman may bo highly infected. The most frequent site of chancre and chancroid is around the head of the penis. This area is covered by the condom if it is used. Therefore, a large number of these venereal dis eases can be prevented by the use of the protective sheath. There are many reasons given as to way the condom is not used. The principal one being that some of the men claim that this de- vice deprives the individual of a portion of the pleasure of the sex act. Our answer to that argument is that it is better to remain free from dis- ease so that repeated sox acts may be indulged in if desired, than for the individual to get infected at one contact and be hospitalized for a long period of time following that contact. One of the important functions of the VDCNCO will bo that of demonstrat- ing the.proper use of the condom. There are several points that must be stressed in a demonstration of this type, 1, The use of the condom from the very first caitact with the girl. 2, The leaving of a small slack space at the end of the rubber, 3. -The use of the full length condom, 4. The demonstration of the proper method of removal of the con- dom as soon as a sex act is completed because of the fact that, if the man permits the condom to remain in the position after withdrawal, he may put a large number of germs from the outside of the condom onto his own body. These germs will continue to live because of the body temperature which is favorable to their growth, and then when he does finally remove' the condom the germs may enter his urinary canal so that ho may have protected himself during intercourse yet may have contracted a venereal disease. The Army provides prophylactic stations which usually are identified by a ’’green”?light so that a man may find this station even though he is in a strange town or camp. Lists are available showing the locations of pro- phylactic stations in many of our cities. Every man who goes on fur- lough should be shown this list for the area to which he is going. During war time the Army trios to locate stations conveniently in towns where many soldiers congregate, so that the man may take his prophylaxis early enough to be effective. This station prophylaxis must be taken within two hours after time of beginning the sex act to be effective. One of your im- portant functions is that of teaching all of the men in your organization where the proplnylactic stations are located in and near your camp. The effort has been made to make the prophylactic stations convenient in loca- tion, to make them attractive, and to provide them with materials so that the men may use them as waiting rooms for the bus back to camp, or a olace pf rest while in town. The men who operate the stations are trained care- fully so that all soldiers may be given proper and prompt protection. Some of the men want only this part or that part of the protective treatment administered. No one can promise any protection unless the en- tire prevention is carried out. Your men should be encouraged to answer the questions that are asked on the prophylaxis slips because this is dene for the protection of the entire area from a problem that exists. It is not the desire on the part of anyone to attend to the personal business of any of the men. It is very important that your men learn to take this protection after every ccn tact whether on pass, on furlough, or whether they have made the contact while the girl is on the field, Two-Tube Prophylactic Kit. One of the failures of the station prophy- lactic has been that the men have not gone to the stations within the ef- fective interval of time. Therefore, the squadrons on the field are pro- vising the individual prophylactic kit that may be listed at the time of the completion of the sex act, even early in the evening so that the men ffiay have some amount of protection, and it is expected that he will avail- him- self of the protection of the station prophylactic later. This type of protection should be encouraged for each man who goes on furlough, because many of the men go to areas where there is no prophylactic station and the loss of time from venereal disease contact while on furlough is just as important and the disease is just as disastrous as if he caught it while in the area, of his camp. One of your very definite duties is that of read- ing the instructions and explaining e-.ch step to the men so that they may knowhow to use this individual protection before they leave camp. Those men going on furlough should be provided with an adequate number of condoms and two-tube kits because at least one case out of every ten has been con- tracted while the man is off on leave. It should be stressed that the tube of vaseline, which ordinarily comes with the ccndoms, is merely a lubricant which has no prophylactic qualities at all. If a man has sox contact in a situation in which he has absolutely no means of protecting himself, a very poor substitute is that of passing his water immediately after the sex act and washing thoroughly and care- fully with any brand of soap and water. One of your talks to your men could easily follow this outline: ’’TAKE A PRO" WHO? Everyone who has intercourse, with anyone other than his own wife, WHEN? Within an hour after every intercourse (even if repeated contacts are with one girl) WHERE? 1. "Pro Station" (1006 Central Ave or Infirmary on Field—Green Light) 2. Two-tube kit when not near a "Pro Station", WHY? 1, Protect your health, 2. Protect health of family, 3. 9 girls our of 10 have a disease because they are not clean. 4. Help your outfit in winning the war. 5. Guard the health of our race, HOW? 1, Demonstrations—proper use of rubbers. 2, Show how to use two-tube kit and explain each step. COMMON FALLACIES IN VENEREAL DISEASE There are many mistaken beliefs about the venereal diseases. The fol- lowing is a list of these fallacies find an answer to repute them, 1. Gonorrhea is merely a strain. Each one of the venereal diseases is caused by a different germ. If you want an apple you go to an apple tree; you do not expect to find apples growing from a banana tree. If a man has a discharge and the laboratory proves that the gonorrhea germ is present, then he has picked up this germ from someone who is carrying the disease, and it is gonorrhea. If a man has had a recent acute page pf gonorrhea and is not completely cured, it can be brought back by sexual intercouse, by drinking, or by straining at heavy work. If a man has been said to bo cured and has been doing any heavy work or drinking or has had repeated sexual in- tercourse over a period of months with no return of symptoms, and then, several months later, the disease shows up again, he cannot claim that tnis is a recurrence of the disease. He has just been fool enough to let lightn- ing strike twice in the same place. 2. Syphilis is merely a ’’haircut”. Ordinarily a break in the skin is necessary for the syphilis germs to entar the body. If the man receives an abrasion or ’’haircut*1 during sexual intercourse, and if the girl is carrying a syphilis gem, he can easily got the germ through tais break in the skin. The sore then develops and lasts for a longer period of time than a simple cut will last. In addition to this the syphilis germ has gotten into the body and is x generalized blood disease, it is not merely a ''haircut”, it is syphilis. 3. The use of iodine will cure a pimple or sore on the penis. This may be true, but the sore of syphilis will go away itself without any treat- ment in four to six weeks. Wo have never been concerned about the sore it- self as being harmful to the individual because it is the late effects of the disease that the individual is interestadin, and bc the time the sore develops the disease has gotten into the body. Any man or woman with a chancre or sore is very dangerous while that sore is present as a sox part- ner, because he or she can pass the disease on to everyone with whom sexual intercourse is had. The person with a syphilis sore needs prolonged treat- ment after the sore has disappeared, 4. It is necessary to have Gonorrhea before a man can prove his man- hood. A man gets gonorrhea only because he did not use his head. Gonorrhea is gotten through carelessness in sexual intercourse in that the individual has not been man enough or smart enough to take care of himself, 5. Sexual intercourse with a virgin will cure gonorrhea. This is a very dangerous notion because the only thing that can be accomplished is further spread of the disease to more^people, Wnen a man has a broken arm, he puts this arm in a cast so that he will not have further irritation of the injured part. The same is true with gonorrhea. If the sex organs are kept at rest, nature will have a much better chance to cure the disease, so no intercourse should be had. le or sore on the penis. This 6. The use of lemon .juice, whiskey, or acidic fluids vdll euro goi- arrhea. Those chemicals are ordinarily very irritating to the urinary channel and will slow down the healing process of nature rather than to assist* 7* Chewing rosin is a cure for gonorrhea* Rosin or cine tar are fre- quently used for curing colds in the head because the vapors can get to the head and nose from the mouth. It is very difficult to see how the vapors of these can get to tne urinary channel. It is very probable that the man who chews rosin or pine tar is putting his sexual organs at rest and that nature is curing his disease, and that this remedy is merely coincidental. 8. Toe much exercise or work vdll bring back an old case of venereal disoas . It is true that heavy work or exercise will cause a recurrence of a recent case of the disease. But if a man has had gonorrhea and has been doing heavy work or drinking, or has been having repeated sexual intercourses, he cannot make valid a claim of this type because if the disease were to re- turn, it would have returned with the first heavy work or heavy drinking after his infection, 9* Gonorrhea will turn into Syphilis, You cannot get a watermelon to grow7 on an ap >le tree, unless you have a watermelon vine in the tree. Gon*- orrhea is caused by one germ; syphilis is caused by another germ. It is very easily possible that a man may get several of the venereal diseases from one girl, but gonorrhea usually shows up within three to five cays after the time of a contact and may be cured in a week or two. Then syphilis, which usually develops in nine to twenty-one days, may show up after the gonorrhea has been cured, 10, Venereal diseases are incurable. Modern medical science has def- inite, positive cures for all of the venereal diseases. If a man wants to have the best chance of cure, he must report for medical treatment as soon as he has any suspicion that he may have a venereal disease. 11. The drugstore or MQuack,! remedies are the best methods to treat the venereal diseases. Those motnods may keep a man from reporting to the medical department of the Army but the man is taking a long chare e of being improperly treated and never becoming cured. He is doing himself a tremen- dous amount of harm because he is preparing his body so tic.t it will carry the disease the remainder of his life by taking poor or inadequate treat- ment. * ' 12• Grandmother or an old herb doctor in the community can provide better treatment than a certified physician. A smart man who has gotten burnt will try to get the best treatment by the most expert of doctors, 13• One case of venereal disease will cause imuunity to further in- fection. A man cannot have syphilis a second time until the first case has been cured. Ho may then get the disease all over again as has happened in a very largo number of cases. Unfortunately, it is true that a man may have gonorrhea once a month every month in the year. In fact, you know- as well as I do that many men have repeated cases of gonorrhea and chancroid which they have gotten from different girls. Granuloma Inguinale and Lymphegranu- loma Verier3urn last usually for several years so that men do not know when they are adding to this infection. 14. An old saying that 11 stiff penis has no conscience11 is extremely true. This is in reality no fallacy but it is just like the story of the fact that the drunken soldier cannot take care of himself. Our attempt should be to educate each man so that he will autociaticaily seek to pro- tect himself at any time there is any danger, which is with each sexual in- tercourse, 15, Sexual intercourse is necessary for good health. Nature has pro- vided its own way of protection of the health of the individual. From a medical vewpoint, it is absolutely unnecessary for a man to have sexual intercourse, but many of your men have made up their minds that they desire this experience repeatedly. It is up to eaei man to make up his mind as to how ho chooses to behave. Too much sexual intercourse can be detrimental to the health of the individual. 16 . Prophylactics will destroy manhood. We have had a number of men who have taken as many as a dozen prophylactics in a month and they have taken this number of prophylactis over a period of months. This should be proof enough that the manhood has not been destroyed by prophylactis. The Army and Navy have put experts to 'work studying to find the best type of prophylactics, which means, one that is safe for the individual as well as effective against the venereal diseases, 17« The use of the condom decreases the pleasure of the sex act. This is more in the mind of the man than is actually a fact, but if the man has this in his mind, impress upon him that it would be better to have a number of sox contacts in which he is protected than it would be to have one contact and get a venereal disease and not be able to have further sex contact for a long period of time. IB, The use of the rubber alone is sufficient prophylaxis. The-proper use of the condom will prevent gonorrhea, but only that, portion of the body that is covered by the condom is protected. Unfortunately, many men have gotten a chancre of syphilis on the thighs or on the stomach, therefore, we must protect those parts of the body that c ome into intimate contact with the girl's body against such diseases as syphilis, chancroid, gra- nuloma inguinale, and lymphogranuloma Venereum, This can be accomplished by the use of thorough washing with soap and water, followed by rubbing-in mercuric ointment (calomel). 19. One prophylactic is sufficient for any number of exposures during Q.ne Uay or one night. The value of the prophylactics can be guaranteed only if it is taken within two hours after beginning of the sex act, 20, One prophylactic is all that is necessary during the entire time in the Army, The man who believes this is thinking in terms of the small- pox vaccination which will give protection over a number of years, but we must teach him that the venereal prophylactic is good only if it is applied within two hours after each sexual intercourse. 21. The toilet seat is a conmon source of venereal disease. The only way to get a venereal disease is from a person who actually has one of the diseases. The germs which cause these diseases die when they are away from the protection of the human body. Thy must have a proper amount of moist- ure, and they must have a proper temperature. Therefore, if they are put on a toilet seat and a minute’s time is allowed in which they can cool down or dry, they die. There is no man foolish enough to go to a public toilet without inspecting it for any pus material, and certainly the man is not going to knowingly expose himself to pus of any kind, whether it is from a boil or from gonorrhea. 22. The presence of venereal disease is negligilble under a full moon« The man’s thinking may be that of romance rather than of protecting himself under a full moon. An apnle is an apple at midnight or at noontime, Syph- ilis is syphilis and may be spread jmst as easily at midnight on a dark nigtyt or on a full moon night; just as easily as in the middle of the day, 23. A nice appearance voids the presence of venereal disease. The ve- nereal diseases do not respect person, social status, race, or profession. A girl dresses nicely to advertise hereself, but she may hide a very bad in-r faction. 24. The venereal diseases are found only in the poor. Many rich and influential people have had venereal diseases, It is only the poor, igno- rant individual who will keep a venereal disease. The smart man seeks im- mediate cure to protect himself, 25• A girl s free from venereal disease because she has been alright in the past. If you know for sure that the girl has not had sexual inter- course with anyone else then she will not have gotten a venereal disease from the last time that you have been with her, but it is occasionally possible to. have intercourse with an infected woman without picking up the infection on that exposure. Any man or woman who has intercourse with a number of people is very likely to get a venereal disease within a short period of time. 26, The Red-Light districts are desirable because the girls are exam- ined regularly. Many different plans for regulation of prostitution have been tried but none of them have been successful in the past, girl may . have been examined at 3 o’clock in the afternoon and afterwards may have had a sex contact with a man with a venereal disease. From that time on, even though she had a very good medical examination, she will spread the disease to anyone who has sex contact with her, 27. The health card is an indication of freedom from venereal disease. The health card is issued to a girl to state that she cannot spread any disease as a waitress in a cafe; she is not usually examined for gonorrhea, and has a blood test sometimes only. She may have had her examination any- time back to the last six months or the last year but she may have gotten any or all of the venereal diseases since that time. How do you knov; that this healtn card was issued to this particular girl? She may not be telling you her right name. 28, It is honorable to conceal the identity of the contact* The girl has burnt you. bhe has not been concerned with your health. She is like- wise causing other men with whom you are living and fighting for your coun- try the same trouble she is causing you. You should try to help protect your friends from a girl who is not interested in anything but the money or the drinks that she can get from you and your ffionds. It is just as impor- tant to the girl to be found by the Health Department, so that she may be treated and thus protect her health, as it is for you take treatment to pro- tect yourself, 29, Some men feel that they can tell whether a girl is clean or not by the following methoas: a. Stick the finger in the ear to* get ear wax and next stick this finger in the girl’s vagina. If she flinches, she has gonorrhea, b, The1 application of lemon juice or sprinkling of black pepper near the contact will show the presence of syphilis, ; Both of these methods will result in complete failure because a doctor, to find the venereal diseases in a woman, must do a very careful physical examination and must depend on several very complicated laboratory tests. Therefore, simple procedures as the above mentioned are absolutely false. As a matter of fact, these false tests have been named to us by men who are in the hospital with venereal disease, which shows that their test did not protect them. 30, The venereal diseases will prevent moving, overseas with your outfit. When a man gets a venereal disease during the time that his unit is alerted, he is given treatment but is sent on with his organization and the doctor of the organization continues the treatment while'this or- ganization is on its way overseas. It will not prevent a man from going overseas. STATISTICAL METHODS The study of f cts.and figures determines the presence of h problem. The proper approach is:— 1. Determine that there is a question to be answered 2. Accumulate data 3. Analyze data, 4. Presentation of problem and solution. You must know that some problem exists, and you must know the impor- tance cf this problem: the obtaining of accurate facts from official sources. * '■' * * It is necessary to compare with similar groups that are capable of being studied together—you cannot compare gro ps that totally dif- ferent. You must know the formula for figuring rate—-N x x - This .is the number of cases that would occur in the or- 4(5) S ganization in a year for each 1000 men if the unit had this number of cases each,month, N—Nurrber of cases reported for the organization for the period $2—Number of weeks in the year 4(5)—‘Weeks in the report period 1000—IfOO strength S—The strength of the organization for which the report is being made. It is necessary to study the figures presented to see where the problem is and how much of a problem you have, aid to draw accurate con- clusions from the ”figures11 so as to have a logical and ,fclear cut'1 idea of where the trouble is and what is to be done to remedy the situation. If important conclusions are drawn, information will then be given through proper channels to the Unit Commander, It is obvious that to got the support of others, you must give them a graphic picture in a brief period. You must be familiar with ways of demonstrating rates and percentages so that the busy Commanding Officer can see at a glance where his trouble is arising. You must make an outstanding picture to show all of the men in the organization where the outfit stands when compared tc other groups on the Base. There are many standard ways of shewing comparative statistics; it might be well to illustrate some of these. We are all familiar with tables of figures. The line graph is frequently seen. DUpp0SlJ we have a series of rates for several years; how can these be shown? 1910, rate of 12; 1915, rate of 9; 1920, rate of 7; 1925, rats of 8; 1930, rate of 6; 1935, rate of 2; 1940, rate of 0; { If we now connect the HX” points we have a graph thus: — The Bar-graph is very useful:— Gonorrhea Flu Pneumonia Syphilis •Each graph must be marked properly so that it is easily seen viiat the rates or percentage mean and what the years or disease represent. The pe graph is useful:— Gonorrhea Chancroid Syphili s Lymph og ra n ulom$ Granuloma Inguinale The use of different sise symbols to represent difference of magni- tude of the problems: — The use of a symbol to represent a number of cases or deaths:— Each * represents 1,000 deaths a year. 1910 * * * # * * 1920 * * * * 1930 * * * 1940 * Thus, we see 7 symbols meaning 7,$00 deaths in 1910 and only 1,000 deaths in 1940, There are several important things to remember about graphs:— 1* Present only a few facts. 2. Make the picture dramatic (by comparison or contrast) 3. Make the problem, simple, outstanding, graphic, complete, and easily understood by every solder, FM 8-55 Medical Field Manual ’’Reference Data” Ini reduction to Medical Biometry and Statistics—Raymond Pearl-W. B. Saunders Co., 1940. EVALUATION OF THE LOCAL SITUATION In any venereal disease control program, it is necessary to have some idea of the conditions in the community near which the camp is located. From authorized sources it is possible to get seme idea of the venereal disease picture of the civilians in the community ccncerned. Quite natur- ally a town that has a high venereal disease rate will help to contribute to a high rate among the members of your command, unless you can sell the soldier on a program of complete protection for himself of his own respon- sibility. It is helpful to know what measures are being taken by the civilian authorities for the treatment and cure of the venereal diseases. It is important for the men of the Army who get a venereal disease to provide in- formation as to where he got his trouble, so that the civilian Health De- partment can treat the girls with whom he has beenin»-contact. In this way the girls will not spread the venereal diseases to other men. In some communities prostitution is allowed to go unchecked. There may be many reasons why this is done. We must remember while we are in the Army that we must help the men in the Army to take care of the Army problem, but we are not authorized to dictate to the City as to how they will handle their own problem. If this type of action is necessary this becomes the responsibility of the Commanding Officer and not of the Don-Commissioned Officers or any of the Medical Officers, It is important to know what recreational facilities are provided in the community for your men. Are there any parks, playgrounds, or natural forms of recreation as a beach, lake, or otherwise? Is there any organized program of recreation in the community—USO, YMCA, or City Baseball Leagues? Are your men thoroughly acquainted with all of the facilities that are available even if they are limited and even if they are not the ideal? Dur- ing wartime we must learn to make the best advantages of whatever facilities are available. Your men get tired of staying in camp; they want to get to town occasionally. You should try to help them protect themselves while they enjoy themselves in town. It is important to know that Army or Navy Prophylactic Stations are available to the men in the community, and it is important that all of your men know the exact location of the prophylactic stations. It is important to know the kind of drinking parlors there are, because many of the men want to drink 'while they are in town. How well disciplined are these parlors? Are they merely the meeting places where the prostitutes and free girls pickup soldiers; do the men think that these mercenary pros- titutes are just charming, local girls, who are trying to help the men to enjoy their stay in town? By the use of a spot map the trouble areas can easily be determined. It is possible to see where the houses of prostitution are. It is possible to see the ”juks joints” 7/horo the girls pickup their customers. It is easy to see where the drinking brawls take place. You should. .Use think of having a spot map showing the men where the churches are to be found; showing them where recreation..;! facilities may be enjoyed, so that they may know where the good as well :.s the evil places are to be found. One of the important things to renew for your men in the answer to the question us to what housing facilities are available for the families of the married men. the repeated and extensive shifting of populations, because of the moving of Army personnel, and thj influx of war workers, frequently it is impossible for us to be able t. move cur families to the area where we are in cam ,j , vtaite naturally a man would prefer to have his wife and his family living near the damp, so that he can enjoy the peace and comfort cf his home. If tliis is not possible, we should try to help the man 'o understand the reason it is not possible, but more than that, we should try to help him to find some place where ais loved ones may live to be near him. The morale 'f your organization depends upon many of these factors. Most communities make very definite efforts to help to answer these prob- lems but sometimes it is necessary for us to help our men to unaerstand why all the problems cannot be answered exactly the way the men feels they should be answered. are in the middle cf u war, and a great deal cf dislocation has taken place. Some of it can bo worked . ut, end some of it will h ve to be cei.*yed until a future cate. Help your men to see the good sice of life under the trying circum- stances, rather th.„.n encouraging them to find f...ult with everything with which they come in contact. Sometimes we just must make up our minds to adjust to the situation and make the best out of unfavorable circumstances. SUBSTITUTIVE ACTIVITIES The old saying-1’An idle brain is the devils workshop” is n true in the anuy as elsewhere. The morale of'any organization is in inverse propor- tion to the venereal rate. Therefore, it becomes evident that as VDChCOs you must concern yourselves with the state cf morale in the organization and how your men occupy their leisure time. rj-'he human body and mind need rest and diversion as much as any machine needs rest. All men are willing to work hard and long under the stress of necessity but you could not expect any group to stand up under prolonged periods cf excessive work without rest and recreation. It will be well here to outline briefly the program of the Army for venereal disease control. The objective cf this program is to reduce the amount of time lost by men who may contact venereal diseases. This program is roughly divided into two parts. 1, The most important part from the standpoint of VI NCCs is com- posed of methods to prevent the venereal diseases, which are; a. Cooperation with the civilian authorities. b. Complete repression of prostitution. c. Provision of adequate prophylactic facilities, d. education of the men, e. Recreation. You will readily see that the VDCUGOs in every organization can be especially instrumental in promoting the last three items of this program. 2. The second part is the reduction in the number of days lost by improve .ent in diagnostic and treatment methods, A previous lecture has been devoted to the program of prophylaxis. The purpose of this entire course is that of giving you a firm foundation upon which to build a program of education for the men of your organization. The Non-Commissioned Officers of each init should concern themselves with helping all of the men within the organization to occupy their spare time. Do you attempt to help the new men feel at home and overcome obsta- cles that frequently confront a rookie, or is it your usual program to for your quarters as soon as the day’s work has been completed at the earliest possible moment? We all must realize that the *rmy is composed of many men who have been picked up from their homes and usual community life and have been thrown together in a strange place and, therefore, are living under very new conditions. The leader in the group can help pro- mote ill will or can lead the mind of the men to constructive use of spare time, depending upon his, the leader’s, desires and efforts. The men of the venereal disease control groups can well use a portion of their time in attempting to organize programs of recreation and athletics for the men of their companies. Vfo should all cooperate and tie-in with the Special Service Officer and his program for the men. There are many forms of activities that a man may engage in to fill his leisure hours so that he may substitute harmless activities for dangerous and promiscuous sex con- tacts. The following list will be an indication to you of some of the things your men may be interested in doing to occupy their spare moments, 1. Athletics 2, Rogligious activities 3 . Games 4. Poster drawing tests 5. Theater parties 6. Classes in Art Sciences or Mechanical Subjects 7. Glee Club, quartets, or band practice, Debating Societies, and a large number of other such programs. Any program, to be successful,, must appeal to a large group. (The spectator at an activity is occupying his time just as well as the active participants; the time consumed in preparing for a program and the many hours devoted to discussing the program afterwards are all part of helping the men to solve the problem of boredom), A VLCNCO was Interested in starting . pittruii discussing ’’better farm- ing methods” because his men were from the farming area. A program of re- creation will take a great deal of time, effort, interest, -and initiative; we must remember that there are those who are responsible for the recreation program, and so our principal function will be one of helpful cooperation. EDUCATIONAL METHODS A simple definition of education is a process of helping your men to ■understand the importance of what you tell them so that they will follow your lead. How can you educate a man to care for himself when he is drunk, for th..t is your greatest problem? Repeat simple facts often enough so that the men think automatically—"contact, followed always by prophylaxis, early’1, The most important thing to remember about education is to talk in terms that all of your men will understand—don't "talk over their heads”; they must not be made to feel that you are ’’talking down" to them. When you are to talk to a group, you must know: — 1. Your subject (do not try to talk about something you are not prepared to discuss). Prepare your subject well—have a written outline. 2. Your audience—Are all of the men highly educated? If so, use selected language and illustrations. If the members of your audience have not had full educational advantages, select your language so each one may know what you mean. Have men to participate in the program to stimu- late interest. £> 3. Your time:— (a) How much time is allotted for your discussion? The snorter the time, the more concise you must be. (b) At what time of day is your discussion? Never arrive late. Try to take advantage of the time of day in your talk. 4. Where you are to meet your group:— (a) Are the circumstances favorable or not? It is im- possible to show effectively maps, charts, and the like, outside on a windy day. 5. What equipment is available:— (a) Blackboard and chalk; motion picture machine—but at the la.-t minute you find that there is no electric current. 6. Educational methods:— (a) Lecture—very poor; puts your men to sleep quickly. (b) Teacher-pupil—have the pupils assist in the teaching; encourage studying, (c) Conference—"round table discussion” is very good if planned in advance, (d) Questions and answers—mav be misused by the lazy teacher; very effective if well planned. (e) Demonstration-most effective if good use is made of teaching aids. "Show them something”. 7. Visual aids—Prepare models* find pisturef, etc,, that will help your listeners to learn by actually seeing. Sush visual aids may be listed as! (a) Posters .(b) Pamphlets (c) Pictures (d) Motion pictures (©) Charts and graphs (f) Maps (g) Models (h) Actual field equipment (i) Organized team in action In summary, teaching of men must bo accomplished by proper preparation, presentation and demonstration by the instructor, application by the student, discussions, supervision, and examination. Educational Methods—Supplement* For distributiofT'to your men: — Posters—Latrine, organization bulletin board, dayroom boards. 1. A supply is maintained at the VDCO Office. Pamphlets:— 1. The Facts about Syphilis (Metropolitan Life Ins Co-New York, N,Y.) 2. Syphilis Health Facts (Afro-American Ins Co) (Atlantic Life Ine Co) (Central Life Ins Co) 3. "It Pay11 (State Health Dept—State Capital) _ 4* ”Our Family are Having Their Blood Tests like Thousands of Others” (State Health Dept) 5. ”Army Against Syphilis” (State Health Dept) 6. ”Syphilis—Its Cause—Its Spread-Its Cure” . (State Health Dept) 7* "Gonorrhea the Crippler” (State Health Dept) 8, ”So Long Boys11 _ . , (State Health Dept) 9. ”Jerry learns a Lesson” (State Health Dept) 10. MCalling All Women” (State Health Dept) 11. ”X Marks the Spot” (List of Florida Prophylactic Stations) \ 12. ”Why let it Bum” (American Social Hygiene Assn-1790 Broadway, New York, N.Y, 13y Prostitution and the War l (Public Affairs Comm Inc-30 Rockefeller Plaza, New York, N.Y, 14.\ Sex Hygiene and the Venereal Diseases, \ (War Department) (For Inductees) Films—suggested for showing to Organizations: — 1, "piagnosis and- Treatment of-*Syphilis” (l£ mm Technicolor sound film. Prepared for professional groups butyls excellent in part's for the men* . (3 reels approximately one hour in length) Information from State Health Dept. #3-4331-Precision Laboratory, 21 W 46th St, New York, N.Y, $200,) 2, “Know For Sure” (Good presentation for average audience, DeLux Film Co-850 10th Ave,, New York, N.Y, $12,&0 3, ”Plain Facts” (Good-12 minutes in length, (American Social Hygiene Assn, $37.50) 4, ’’Health is a Victory” (Gonorrhea in industry-of only fair interest for average audience) (American Social Hygiene Assn*. 12 minutes in length) 5* ”In Defense of the Nation” (Not of special interest to Army groups, 12 minutes in length) (American Social Hygiene Assn) 6, ’’With These Weapons” (interesting history of fight against Syphilis) (American Social Hygiene Assn) 7, "Let us Fight Syphilis” (Shows community responsibility in venereal disease control.) (U. S, Public Health Assn. 20 minutes in length) 8. "The