IJE Advance Access originally published online on August 8, 2005
International Journal of Epidemiology 2005 34(5):1173; doi:10.1093/ije/dyi158
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Published by Oxford University Press on behalf of the International Epidemiological Association
Letter to the Editor |
Limitations of the syndromic approach in South Asia
Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada L8S 1A4. E-mail: kumarak{at}mcmaster.ca
Sir—I was most interested to read the article in your April edition entitled ‘Why do women complain of vaginal discharge? A population survey of infectious and psychosocial risk factors in a South Asian community.’1 This is an important study with significant policy implications.
I am a physician/anthropologist who lived and worked in India over an 11 year period. I have commented on the mistranslations that can occur when a symptom with deep cultural meanings is interpreted with only biomedical meanings,2,3 and have hypothesized that South Asian women complaining of vaginal discharge are using a ‘language of the body’ to express distress about a range of social conditions.4 Many women who complain of vaginal discharge also report other somatic symptoms such as dizziness, backache, burning hands and feet, and weakness. Presence of these symptoms may aid in the diagnosis of vaginal discharge of non-infectious aetiology.
In this study, sexually transmitted infection (STI) prevalence is low, and the symptom of vaginal discharge does not correlate with the presence of the STIs. This study adds to the evidence that the syndromic approach to the treatment of STIs in South Asian women is not justified and leads to significant over-treatment with all its associated negative effects, both in areas of low prevalence of STIs5,6 and of high prevalence.7
This study also shows that the symptom of vaginal discharge is only weakly correlated with the presence of reproductive tract infections (RTIs) such as candidiasis and bacterial vaginosis, diseases that have much less clinical significance than STIs. Positive cultures for these organisms may represent colonization rather than true infection in many cases. The costs of eradicating these organisms is high, recurrence is common, and in most places the treatment costs must be borne by the patient. A study from Rajasthan showed that families are spending more money in seeking care for treatment of symptoms of RTI than they spend on child health care and safe motherhood care.8 There is also an important opportunity cost involved—clinicians are themselves scarce resources, and should not spend their time occupied with treatments that have doubtful efficacy.
Since cultural beliefs about genital secretions as ‘vital essence’ are common in both men and women in South Asia, an evaluation of the syndromic approach in men complaining of urethral discharge might also reveal significant overreporting of the symptom with consequent over-treatment. In the cultural context of South Asia, the syndromic approach in both men and women may result in wastage of scarce resources. Instead, a strengthened focus on primary prevention of STIs might be a more cost-effective strategy in South Asia.
References
1 Patel V, Pednekar S, Weiss H et al. Why do women complain of vaginal discharge? A population survey of infectious and psychosocial risk factors in a South Asian community. Int J Epidemiol 2005;34:853–62.
2 Trollope-Kumar K. Symptoms of reproductive tract infection—not all that they seem to be. Lancet 1999;354:1745–46.[CrossRef][Web of Science][Medline]
3 Trollope-Kumar K. Cultural and biomedical meanings of the complaint of leukorrhea in South Asian women. Trop Med Int Health 2001;6:260–66.[CrossRef][Web of Science][Medline]
4 Trollope-Kumar K. Speaking Through the Body: Leukorrhea as a Bodily Idiom of Communication in Garhwal, India. PhD thesis, McMaster University, Hamilton, Ontario, Canada, 2001.
5 Hawkes S, Morison L, Foster S et al. Managing reproductive tract infections in women in low-income, low-prevalence situations: an evaluation of syndromic management in Matlab, Bangladesh. Lancet 1999;354:1776–81.
6 Bogaerts J, Ahmed J, Akhter N, Begum N, Van Raanst M, Verhaegen J. Sexually transmitted infections in a basic healthcare clinic in Dhaka, Bangladesh: syndromic management for cervicitis is not justified. Sex Transm Infect 2001;75:437–38.
7 Desai VK, Kosambiya JK, Thakor HG, Umrigar DD, Khandwala BR, Bhuyan KK. Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis in female sex workers of red light area in Surat, India. Sex Transm Infect 2003;73:111–15.
8 Indian Institute for Health Management. Financing Reproductive and Child Health Care in Rajasthan. New Delhi: USAID, 2000.
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