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12/7/2014 History of Sexually Transmitted Infections in Egypt ; Historical perspectives Presented by Dr Adel Botros Zaghloul Consultant Dermatology and STI Al Haud Al Marsoud Hospital Consultant STI, WHO and FHI EMRO, Genéve Former Fellow at UTMB ,Galveston, TX, USA American Academy of Dermatology Intl’ fellow Ancient Egypt Egyptians developed one of the world’s earliest civilisations Egyptian civilisation produce,Giza pyramids, temples, tombs, and the death mask of “ Tutankhamun” Egyptian developed the world’s first first mythologically based religion , with an assurance of an after life 1 12/7/2014 Ma’at Egyptians cherished and practiced what they called Ma’at A sense of good order in both the conduct of their private affairs and their political institutions Ancient Egypt Ancient Egyptian society flourished for more than 3,000 years In the last few hundred years BC , Greek influences became strong in Egypt In 30 BC , Egypt became a province of the “Roman Empire” this was followed by the influence of Christianity Today and for more 1300 years the Muslim faith has predominated 2 12/7/2014 Egypt Geography Natural defenses extensive desert to the west and east Sea to the north and east Egypt’s geographical setting favored long periods of peace Nile flood with the abundance of sunshine made to harvest two times per year Farmers went to work for the Pharaoh in order to pay taxes Egyptian Society Political and Economic structure Egyptians believed their pharaohs to be descendant of the sun god Ra Swings from poverty to prosperity, well-recognized as determinants of epidemic levels of sex infections were non-existent in Ancient Egypt The population of Egypt’s towns was small 3 12/7/2014 Egyptian Society social structure Families formed the strong fundamental fabric of Egypt’s closely –knit society Girls trained in household affairs in the home with their mothers Boys, often from the age of 8 became apprentices with their fathers eg, potters Some boys aimed to follow their fathers and become scribes Family life The Nile River was the place where most people went to relax. The Nile was used for fishing, boating, swimming, etc… Egyptians also loved music, and they often had parties and festivals with music and dancing 4 12/7/2014 Marriage and Sexuality To marry and have children was seen as a most welcome duty The majority of girls, married between 12-13 years and the boys at a year or two older Menstruation began around 14 years and marked the change from childhood to womanhood Sex is a sacred, beautiful and meaningful act Sexual Life in Egypt Egyptian wife viewed herself and her husband as a companions Divorce was not common In contradistinction to Greece and India Egyptian temples were not used to house prostitutes 5 12/7/2014 Sexual practices Premarital sexual activity is rarely mentioned Prostitution was acceptable only as behaviour of bachelors, soldiers, men away from home for extended periods The towns of Abydos and Deir el Medina adjacent to major building projects had houses of prostitution Leca, mentioned the punishment for rape was : “ l’amputation des organes genitaux” Sexually transmitted disease in Ancient Egypt Hyksos invaders departure around 1557 BC, many Egyptian soldiers returned back home with urethral discharge Ebers papyrus ( 1555 BC) was found in a temple at the city of Abydos, recommends to treat leucorrhoea and burning micturition with (Balanites aegyptiaco with honey, copper and antimony) According to Ghalioungui PID, must have thrived , among builders in Deir el Medina and Abydos 6 12/7/2014 Primary prevention at the time of Pharaoh Egypt’s social structure and the orderly way it functioned favoured prevention Population in Ancient Egypt was static Early marriage without adolescent period secured against STIs Stable hierarchical political structure made for a near permanent state with consistency and continuity for more than 3,000 years Exodus of Israelites from Egypt The exodus of the Israelites 1280 BC from Egypt, to Sinai, after some 400 years Moses departed to the mountain and stayed there for 40 days in order to receive the 10 Commandments Moses broke the first set of the tablets of stone after returning from the mountain Apis sacred bull During their 40 years in Sinai “wilderness” they did battle with the Midianites 7 12/7/2014 Israelites Campus After returning from the battle with 24.000 Midianites women, Moses’ troops in Sinaï suffered from the “issue” Moses recognised that the “issue” was associated with sexual intercourse Moses ordered a quarantine for one week away from the camp ( Numbers 31) Prostitution in Egypt 19th & mid 20th century Prostitute was considerably stratified in terms of social class “al-jawari”, a term that originally designated slave girls and ethnic origin “al-ghawazi” mainly from gypsy tribes Prostitution in Egypt evolved yet another stratum , with the influx of European immigrants after the British occupation 1882 -- women of primarily Italian, Greek and French origin 8 12/7/2014 Transmission Dynamics A. Core group: high-risk persons: High rate of infection Frequent changes of sexual partner B. Bridging population: Social condition e.g., single, teenager Economic condition e.g., poverty York et al., Dynamics & control of the transmission of gonorrhea. Sex Transm Dis 1978 ; i74( suppl 2): (S 134- S 143) History of legal prostitution in Egypt In 1882 the ministry of interior issued a nine-article edict regulating the relationship between prostitutes and the authorities. In 1896 an ordinance on brothels was issued. In 1905 a law regulating the issue was passed. In 1922 prostitution was codified and legalised. 9 12/7/2014 Lock hospital Al Haud Al Marsoud Hospital (1902) Lock hospitals were used to confine and treat prostitutes Some medical and disciplinary exercise to control STIs and prostitute No other adequate mean of medical policing could be found The incidence of STIs continued to rise despite the regular inspection and confinement of infected prostitutes STI hospital, prostitution zone, Brothel house 10 12/7/2014 Tertiary Syphilis Syphilis treatment and fate Late in the 19th century and early in the 20th century mercury and its compounds were widely used to treat STI’s By the 1920s Salvarsan and neosalvarsan were used, but some doubts were expressed about their safety and efficacy in syphilis 1930s full-body fever machine 11 12/7/2014 Rules to be followed by the examining venereologist 1. All parts of the body must be examined 2. Newest tools of medical science must be used. 3. Examination must be combined with councelling Prostitution, and VD a political hornets’ nest (1922-1949) " Slaughterhouses of Virtue" & "Official prostitution in Egypt." by Sheikh Mahmoud Abul-Uyun Two articles put the authorities under considerable pressure, to the extent that the public prosecutor announced he would issue a detailed report on the case The existence of prostitution in a country where the constitution stipulates that Islam is the state religion "was an unsatisfactory situation that can please no one.“ The public prosecutor defence , referred to the tragic results of the closure of the prostitution quarters Rise in the rate of VD following this action that the citizens , pressed for the renewal of the permit to reopen the prostitution quarters 12 12/7/2014 Negligence of STI in Egypt Official preoccupation with “major” epidemic diseases with high morbidity and mortality levels Powerful cultural, social and economic forces which have facilitated the spread of STIs, while inhibiting their effective observation and control Dermatologist which are supposed to be venereologist are not interested in the whole issue Patients are reluctant to be examined Treatable but Incurable Sexually Transmitted Infections A shift from curable infections towards treatable but incurable viral diseases , such as HPV, HSV and HIV has changed the SCENE substantially In disciplines treating STIs ,the last decades has been a challenge 13 12/7/2014 The role of health services in STI prevention and care Total population asymptomatic Infected with STI Partner notification, case finding, screening Seeking care Correct diagnosis Correct treatment Treatment completed Cure Promotion of health care seeking behaviour Improve quality of care Attitudes of personnel Syphilitic Chancre + Molluscum Contagiosum + Venereal Wart Venereal warts Chancre Molluscum contagiosum 14 12/7/2014 Old Fears come back HIV/AIDS 1980’s Old fears in the early 1980’s combined with popular and media homophobia were transferred to this new menace Terror of innocent infection through lavatory seats, or shared utensils Revulsion from doing anything for sufrrers being transmitted through sexual relations Demands that “ something to be done” Prostitutes should be licensed again and regularly inspected Tensions between government and voluntary organizations Conflicts between the interventionist school and the religio- moral lobby Current MOHP Efforts to Standardize Quality RTI/STIs Activities Collaboration between Curative and Preventive Care National HIV/STIs Surveillance plan National Guidelines for the management of STIs STIs training curriculum Establishment of Pilot STI clinics: Cairo Skin and STI Hosp. (El Haud El Marsoud) STI clinic in Alexandria (Karmooz) Sharm El Sheikh 15 12/7/2014 STI Program in Egypt Training Manual Poster National Guidelines STI Clinic Inauguration Cairo-Alexandria-Sharm 16 12/7/2014 The First Step Toward Eradication of STI “As a disease control program approaches the end-point of eradication, it is the program not the disease ,which is more likely to be eradicated” 17 12/7/2014 Thank you 18