Lessons from China: Premarital medical examination

[Guest guest]

Dear colleagues,

I wish to share a very recent paper published in the

highly respected medical journal [bMJ 2003;326:277-279

( 1 February issue)] on a debatable but very

informative and critically analyzed issue of medical

fitness certificate needed for marriage in China. The

review is written by Therese Hesketh

[http://bmj.com/cgi/content/full/326/7383/277]

[While reproducing the article I have

inserted my views within brackets].

The authors writes that this process consists of the

completion of a standard checklist by a medically

qualified person. Inquiry is made about hereditary

illness and problems that might jeopardise parenting

abilities, such as learning disorders and psychiatric

problems. The physical examination includes the

obvious height, weight, and blood pressure and the

rather less obviouscolour and distribution of hair. In

men these are feminisation of breasts, pubic hair

(present, absent, or sparse), phimosis, size of testes

and epididymis, presence of varicocoeles, and so on.

In women the pelvic examination is supposed to include

palpation of the uterus and ovaries. Blood tests

usually include a full blood count, liver function

tests, and testing for hepatitis B surface antigen {I

suggest even VDRL and HIV be included]. Laboratory

tests are carried out for gonococcus and sometimes

trichomonas and chlamydia, depending on the technology

available.

After the examination, couples receive premarital

health instruction. This usually comprises a video

about producing healthy children and how not to have

more than the allotted number. Some videos have

pictures of children with grotesque abnormalities, as

an apparent warning to do everything advised to ensure

against such disaster [Here in my opinion video on

HIV/AIDS and its transmission should also be

included].

Films are sometimes followed by a multiple

choice test to check that the couple were paying

attention [ I like this idea very much].

Depending on the results of the examination, couples

fall into one of three categories. Couples who meet

the requirements are issued with the certificate of

health for marriage. In other cases the marriage must

be postponed to allow for some form of treatment or

counselling. [The third category means permanent

unfitness for marriage and producing children].

This practice, is easy to criticise, ethically, on

grounds of human rights, control, oppression, and

eugenics. But many countries have recognised the

usefulness of screening couples before they embark on

their reproductive lives. [The authors writes that]

Over time, premarital screening has been used for a

range of conditions: syphilis, rubella immunity,

haemoglobinopathies, Tay-Sachs disease, hepatitis B,

and, most recently, HIV. Taiwan, Turkey, Egypt, Spain,

Portugal, Italy, and Brazil all have a form of

premarital medical examination.

[ In vedic India also, such mentions of premarital counselling and unfitting

the princes by their family guru's can be fond].

Oviously, from a public health point of view it is not

hard to justify such an examination: reasons include

diagnosis and treatment of unrecognised diseases,

reduced transmission of disease to partners and

offspring, a forum for health education, and a

convenient means of collecting information on the

health of the population for epidemiological and

planning purposes.

Voluntary counselling and testing

for HIV at the examination has been recommended as one

means of preventing spread of the infection The major

argument proffered for the examination is its use in

preventing the transmission of genetic

disordersparticularly desirable in a population where

autosomal recessive disorders, such as the

thalassaemias, sickle cell disease, and Tay-Sachs

disease, are relatively common. The prevalence in

southern China of genes for and thalassaemia is high,

and some examination centres carry out initial

screening by measuring red cell mean corpuscular

volume to identify carriers.

In some Mediterranean

countries premarital screening for haemoglobinopathies

is well established. A programme in Denizli, Turkey,

found that in 15 of the 9902 couples screened, both

partners were carriers of the thalassaemia trait.

After genetic counselling, two of the couples

cancelled their marriages, and other couples sought

prenatal diagnosis.

[ I think now other countries

including India should also follow China to combat HIV

epidemic particularly after the supreme court has

already justified that right of individual is

superceded by the right of the society and the family-

would be wife and their children].

The premarital examination in authors view [ as well

as in my view] provides opportunities for health

education. In a few areas, health education given as

part of the premarital medical examination now

includes information on HIV and sexually transmitted

diseases, but the educational opportunities could be

exploited further. For example, given that two thirds

of Chinese men smoke, and that many children are

introduced to smoking by their fathers, the

examination would be an ideal forum to emphasise the

dangers of active and passive smoking.

[overall this article clearly justifies the premarital

medical examination and counsellng and shows that

benefits over scored the human right and ethics].

Dr. Sarman Singh, MD. MNAMS

Head, Division of Clinical Microbiology

Department of Laboratory Medicine

All India Institute of Medical Sciences

P.O. Box. 4938, Ansari Nagar

New Delhi-110 029, India

Phone: 659 4764, 659 4977, 652 8484

Fax: 686-2663, 652 1041

E-mail: <sarman_singh@...>