Stress brought about by poverty can trigger leprosy reactions (?)

Leprosy Mailing List – April 5^th, 2011

Ref.:   Stress brought about by poverty can trigger leprosy reactions (?)

From: Warren G., Sydney, Australia

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Dear Salvatore,

I was interested in the heading “Stress brought about by poverty can trigger leprosy reaction”  and the comments by Dr Barminus – yes lots of patients require security.  In his patients, security came from acceptance and a steady job.  Please may I suggest that anything at all that causes stress can be blamed for leprosy reaction, and often is. 

Unfortunately too many people blame leprosy on the presence of poverty- when in fact we certainly find leprosy in areas where there is No poverty.  So it is not the poverty that causes leprosy.  The fact is that where there is leprosy we find poverty because of the social problems due to leprosy and  the problems of getting employment and adequate support.  Please can we  make the change so that people know that it is leprosy, and the social stigma and disability that causes the poverty, or maintains it, and Not the other way around.  There were many patients in prisoner of war camps (1942-5) who were very under fed, even starved, and one could say lived in severe poverty.  They showed no reaction till after the war their general living conditions  and medical conditions improved and  the body could stop the fight to stay alive and could turn its attentions to the problems caused by the medical presence of leprosy. Their poverty was over, then they showed reaction, which was often very difficult to control.  Real problems with reaction were seen over the next 5-10 years.

Then yes, I agree -  stress can result in clinical ENL or other leprosy reactions.  Stress due to anything can be the trigger.  I have seen many patients in hospital doing well till they receive news that a family member has been ostracised because it has become known that the patient now in hospital has leprosy. Another girl went into a leprosy reaction after being free of it for  many months when it was suggested she leave hospital and return home.  She knew that she would be stigmatised, not accepted in the home.  Yes part of the prevention of reaction is definitely social education as well as elimination of other medical conditions.  Another patient had chronic ENL till a friend of his wrote to his wife in a foreign country that he had escaped from, and told her he was dead so she could marry someone else and would not be ostracised because she was the wife of a man with leprosy.  Once he heard she was Ok he rapidly improved. Stress can be caused by many things, but without the social stigma and its complications, I would challenge that poverty is not the main cause.  One of the essentials is education of the general public as well as attempting to provide the patients with the  means of supporting themselves with dignity in the community.

We used what we called “happy tablets” some 40 years ago.  I found valium was too much of a sedative.  Plain phenobarbital was enough for some of the milder cases. Chlorpromazine (largactil) also proved excellent for the more severe ones, especially if medically they really needed a rest.  It can be tailored to provide a good level of sedation but the patient is able to feed and bath and exercise himself!  Later on we found Amitriptyline seemed to be a happy compromise for many of those in the middle of the severity spectrum.  It may be wisest to discharge patients on a low dose of Amitriptyline.  Or something similar as things available vary in different countries.  For those who have had steroids the discomfort of the withdrawal symptoms is enough to send any patients into ENL- I have seen it many times.  They complain of symptoms of ENL without showing any real signs on the surface.  In the long term management of these patients we must provide social and psychological support as well as good medication and treatment for all medical conditions present, if we are to prevent them returning year after year with “funny symptoms”, said to be reaction.

Hoping we can help in the adequate long going care of our patients.

Grace Warren

Previously adviser in Leprosy and reconstructive surgery for The Leprosy Mission in Asia ( 1975-1995)